Uberization of Nursing

“Uberization" is a catchphrase that has quickly become part of common parlance in discussions about the pandemic-induced economy. Uberization is the movement by organizations to “replace fixed wage contracts with ‘dynamic pricing’ for labor” (Davis, & Sinha, 2021).  It is transforming many elements of the economy and replacing employees employed by the organization with a type of self-employed or contract employee. In essence, it allows businesses to “recruit labour at a large scale in new ways” (Davis, & Sinha, 2021). 

The global business community has had a range of responses to the trend of uberization (Babali, 2019), as has the healthcare industry in particular.  Yet as health systems emerge from the pandemic, Bloomberg reports that “the ongoing elevated costs of [healthcare] workers are causing profit warnings” (KHN, 2022; Court, & Coleman-Lochner, 2022). Regardless of one’s resistance or acceptance of uberization, healthcare employment is in crisis. Change must occur to keep health systems from financial disaster.

It seems that the tide of uberization in the healthcare industry is already rising. An increasing number of employees are contracting with hospitals and health systems via a staffing agency. This trend is likely to evolve, with a portion of staff employed directly by the hospital, and the remaining employees self-contracting with hospitals or health systems with short-term or even daily contracts. In fact, hospitals are reporting that rather than temporary “travel nurses” coming from other states to work on a contract basis, nurses are taking short-term contract work at hospitals a short drive from their own homes rather than pursue permanent employment with these organizations.  We are witnessing the uberization of nursing, which will eventually extend to other healthcare occupations.

Why uberization?

The healthcare workforce shouldered the heavy burden of fighting the COVID-19 pandemic. Yet a collaborative study from Indiana University, the nonprofit Rand Corp., and the University of Michigan that analyzed the changes in the U.S. healthcare workforce during the COVID-19 pandemic found that “the average wages for U.S. healthcare workers rose less than wages in other industries during 2020 and the first six months of 2021” (Toler, 2022; Cantor, Whaley, Kosali, & Nguyen, 2022). According to a February 2022 report by the U.S. Bureau of Labor Statistics, only about 35 percent of healthcare and social assistance organizations “increased wages and salaries, paid wage premiums, or provided bonuses because of the COVID-19 pandemic” (U.S. Bureau of Labor Statistics, 2022).

Due to the media attention the “Great Resignation” has received, it is common knowledge that workers across industries have been leaving their jobs at higher rates than before the pandemic (Parker, & Horowitz, 2022).  Yet by October 2021, when the “quit rates” were at their highest recorded levels, healthcare and social assistance job resignations had increased to 35% higher than they had been before the pandemic, slightly higher than the increase of resignations among all workers in the same period (29%) (Wager, Amin, Cox, & Hughes-Cromwick, 2021).  

Over the last ten years, “the salary of registered nurses increased by 1.67 percent in the United States” (Michas, 2021). Whereas healthcare executives make on average eight times more than their hourly employees (Saini, Garber, & Brownlee, 2022). The pandemic has rebalanced the scales in favor of those underpaid for many years. The salary landscape has changed, and in response many hospital systems blindly grasp to the pre-pandemic state of agency staffing. This, combined with near flat salary increases, contribute to the uberization of healthcare.

For many healthcare professionals, the combination of work-related stress and incommensurate compensation was the final straw. However, in addition to fair salary, flexibility has become a top demand of employees—even in healthcare. “Gone are the days when job security or pay was everything. Workers now are giving more thought to how their jobs fit into their lives. Ambition for ambition’s sake is being reassessed” (Buckingham, & Richardson, 2022).

A recent survey articulated “higher pay and dissatisfaction with management were also key drivers of nurses changing work settings in 2020 or 2021,” with 28% of respondents saying they've changed work settings (Lagasse, 2022). The percentage of nurses considering changing employers increased by 6% from 2020 to 2021, with 17% saying they are contemplating making an employment change. The percentage of nurses who are “passive job seekers – not actively looking for a new job but open to new opportunities – also increased, from 38% in 2020 to 47% in the current survey” (Lagasse, 2022).

The moment: contractor or non-contractor

As the trend of uberization continues to spread beyond the transportation industry, the global business community should be watchful of challenges that the trendsetter Uber is facing to understand future implications of this movement in their own industry. For example, recent legal battles regarding the employment status of Uber drivers will likely impact the cost-benefit analysis of those considering traditional employment or independent contracting. While an independent contractor is free to offer services to anyone and doesn’t have the limits on their freedom that comes with being an employee of a single organization, the U.S. National Labor Relations Board decision that Uber drivers are independent contractors means that drivers have no federal right to unionize (HyreCar, 2021; Fishman, 2020). In Europe, however, Uber drivers are considered employees and not independent, which could mean that unionization could occur en masse.

The future

The future of healthcare employment could be via an app on smart phones. Imagine: daily staffing supplemented by workers employed and credentialed through the app. The healthcare worker could choose their rate and shifts, and the hospital could determine the desired experience, quality, and patient experience reviews for the open position. It could shift the future of employment healthcare significantly.

The rate of change in today’s workplace is accelerating whether it is through the uberization of healthcare workers or advancements in workers’ rights. A recent New York Times article entitled “The Revolt of the College-Educated Working Class” states: “The support for labor unions among college graduates has increased from 55 percent in the late 1990s to around 70 percent in the last few years, and is even higher among younger college graduates” (Scheiber, 2022).  

This may have a ripple effect on the healthcare workforce. Years of stagnating salaries and organizations’ undefined workforce vision has primed the industry for action with record job-quits within healthcare. This has proven especially true in rural markets where recruitment of permanent and agency staff has posed numerous challenges. Our current climate potentially opens the door for workers to leverage themselves via the advocacy of a union.   

Summary

The labor supply and demand are out of balance. The long-term effects on the health sector labor market from the pandemic are unknown, but changes in healthcare delivery (such as the growth of telehealth) may lead to lasting shifts in the healthcare industry. Fierce competition for healthcare workers means that employers must go beyond good pay and benefits to attract the best candidates. Healthcare recruitment is a zero-sum game. There isn’t a pool of healthcare workers lying idle, and so recruitment is often at the cost of a competitor. The employee knows that this demand exists, and this could further drive the uberization of healthcare workers. However, there is potential for this new movement to benefit both parties. As limited number of employees equates to skill scarcity which drives salaries, hospitals could utilize their skilled workforce based on need and demand. 

Resources

Babali, B. (2019). What is Uberization? The Business Year.

Buckingham, M., & Richardson, N. (2022). What’s Really Driving the ‘Great Resignation’. Barron’s.

Cantor, J., Whaley, C., Kosali, S., & Nguyen, T. (2022). US Health Care Workforce Changes During the First and Second Years of the COVID-19 Pandemic. JAMA Health Forum. 2022;3(2):e215217.

Court, E., & Coleman-Lochner, L. (2022). ‘Unsustainable’ Squeeze Grips U.S. Hospitals on Covid Labor Cost. Bloomberg.

Davis, G., & Sinha, A. (2021). Varieties of Uberization: How technology and institutions change the organization(s) of late capitalism. Sage Journals, 2(1).

Fishman, S. (2020). Uber Drivers are Contractors Not Employees According to the NLRB. NOLO.

HyreCar (2021). Are Uber Drivers Employees or Independent Contractors: Explained. HyreCar

KHN (2022). Hospitals Losing Money, Thanks To Covid-Driven Cost Increases. KHN Morning Briefing, April 28, 2022.

Lagasse, J. (2022). Almost 30% of nurses are considering leaving the profession. Healthcare Finance News.

Michas, F. (2021). Average annual salary of registered nurses in the United States from 2011 to 2020. Statista.

Parker, K., & Horowitz, J. (2022). Majority of workers who quit a job in 2021 cite low pay, no opportunities for advancement, feeling disrespected. Pew Research Center.

Saini, V., Garber, J., & Brownlee, S. (2022). Nonprofit Hospital CEO Compensation: How Much Is Enough? Health Affairs.

Scheiber, N. (2022). The Revolt of the College-Educated Working Class. The New York Times.

Toler, A. (2022). Health care wage growth has lagged behind other industries, despite pandemic burden. Indiana University.

U.S. Bureau of Labor Statistics (2022). 24 percent of establishments increased pay or paid bonuses because of COVID-19 pandemic. U.S. Bureau of Labor Statistics.

Wager, E., Amin, K., Cox, C., & Hughes-Cromwick, P. (2021). What impact has the coronavirus pandemic had on health employment? Peterson-KFF Health System Tracker.

I Want to Believe

By Kim Bellard, May 26, 2022

I know, I should be writing about hot topics like monkeypox or the baby formula shortage, but, c’mon, Congress held hearings last week about UFOs — the first in 50 years! I mean, I followed Project Blue Book in the 1970’s, watched “The X-Files” in the 1990’s, and have seen UFO videos on YouTube. If Congress is starting to take UFO’s seriously, how could I not?

And for those of you who don’t see any possible connection to healthcare (except for those unpleasant alien probes…), let me put it to you this way: by 2050, is it more likely that:

· We’ll know what UFOs actually are;

· We’ll have fundamentally reformed the U.S. healthcare system.

I thought so.

So, maybe UAPs are, indeed, aliens. Maybe some John Galt-type character has formed his/her/their own “men of the mind” collective to create new technologies for their own use. Maybe they’re all really only swamp gas. What we know is that we don’t (yet) know.

The intriguing thing to me is that they just seem way beyond our capabilities, beyond our understanding. They mystify us. They make our technology seem outdated. They sometimes seem to defy the laws of physics. Astrobiologist Hagg Misra told Science News, “Maybe they’re a sign of something like new physics.”

That, my friends, is exciting.

I like to think that UAPs were built in some teenager’s garage, using off-the-shelf materials in some novel way, piloted out by that teenager and his/her/their buddies out on a joy ride. Whether that garage is in Des Moines or Alpha Centauri, I don’t much care.

I love things that put us in our place, that remind us we don’t have all the answers, that open our minds to the realization that there’s a lot left to learn. 

Moral of the story: if you think you know how our healthcare system works and the constraints it must have, maybe you need to be open to healthcare’s UAPs — unidentified alterative possibilities.

In “The X-Files,” Fox Mulder’s unspoken (but not unwritten) mantra was “I Want to Believe.” As it turned out, there were UFOs, the aliens were among us, and there was an alien/government conspiracy. Sometimes being the lone believer isn’t crazy.

I want to believe in a healthcare system that is radically less expensive, much more effective, and delivers on health equity. I’m all for any new physics — or, I suspect, new biology — that helps us accomplish that healthcare system.

I’m waiting for the pill that fixes genetic defects, the harmless beam that destroys incipient cancers, the relentless nanobots that prevent strokes and heart attacks. I want the kind of healthcare I see in science fiction.

In today’s healthcare system, such miracles would find the pill hugely expensive, the beam’s side effects so bad that they might outweigh the benefits, and the nanobots prone to being hacked. Instead of technology being so advanced that it is indistinguishable from magic, as Arthur Clark put it, in healthcare we get magic that overpromises, underdelivers, and costs too much.

Our healthcare system is a lot like those military aircraft — slow to change, incomparably costly, highly technical, reliant on skilled operators, disturbingly fragile, and deeply indebted to the healthcare/industrial complex. I hope for a healthcare UAP to outmaneuver them like a kid on a joyride.

I don’t want everyone to suddenly believe in UFOs, nor do I want anyone to assume that their technologies are beyond our capabilities. I do want us to let them open our minds to the possibilities they suggest.

Similarly, there are plenty of sightings to suggest that our healthcare system could be much better, but we’re going to need some true believers to make it so. Are you one of them?

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)  

Examining Unnecessary Medicare Patient Surgeries During First Year of Pandemic

by MCOL Staff, May 20, 2022

The nation’s hospitals performed more than 100,000 unnecessary and potentially harmful procedures on older patients between March and December 2020, according to a new analysis by the Lown Institute, a healthcare think tank. Coronary stents and back surgeries were among the most-performed unnecessary procedures over this period.

The analysis of Medicare claims data shows that thousands of vulnerable patients were admitted to U.S. hospitals during the height of the pandemic, before COVID-19 vaccines were approved, for procedures that offer little to no clinical benefit or were more likely to harm patients than help them. The analysis of eight unnecessary and potentially harmful procedures is the first to measure rates of overuse at U.S. hospitals during the COVID-19 pandemic.

“You couldn’t go into your local coffee shop, but hospitals brought people in for all kinds of unnecessary procedures,” said Vikas Saini, MD, president of the Lown Institute. “The fact that a pandemic barely slowed things down shows just how deeply entrenched overuse is in American healthcare.”

Volume of eight low-value procedures in U.S. hospitals per Medicare claims

• Stents for stable coronary disease: 45,176 (42%)
• Vertebroplasty for osteoporosis: 16,553 (16%)
• Hysterectomy for benign disease: 14,455 (14%)
• Spinal fusion for back pain: 13,541 (13%)
• Inferior vena cava filter: 9,595 (9%)
• Carotid endarterectomy: 3,667 (3%)
• Renal stent: 1,891 (2%)
• Knee arthroscopy: 1,596 (1%)
• Total unnecessary procedures identified: 106,474

Coronary stents were the most overused by volume of all the procedures. Across the country, approximately one in five met criteria for overuse, including at some of the nation’s most well-regarded hospitals. For example, among the U.S. News top 20 hospitals, all had rates of coronary stent overuse above the national average, and four had rates at least double that: Cleveland Clinic (44%), Houston Methodist Hospital (44%), Mt. Sinai (42%), and Barnes Jewish Hospital (42%).

For this analysis, the Lown Institute used data from the 100% Medicare claims database from January – December 2020 to evaluate volume of overuse for eight common low-value procedures. Procedures and overuse criteria were based on Lown’s previously published research into measurement of low-value care at hospitals

What do Copernicus and Today’s Healthcare Leaders Have in Common?

By Maria D. Moen, May 13, 2022

Both Use Data to Change the World as We Know It 

In 1543, Copernicus was the first astronomer to propose the theory that the earth and other planets rotated around the sun, which contradicted popular thought at the time that the earth was the center of the universe. Through mathematical and astrological analysis over the course of many years, Copernicus effectively moved the sun to the center of the universe with his simple and elegant explanation of the retrograde motions of the planets.

Today, a similar “Copernican Shift” is taking place in healthcare as innovative leaders tackle the hard problems of staffing shortages, reduced patient loyalties due to trust and health equity concerns related to the healthcare system as a whole, and the need to bring forward strategies for growth to rebuild their own particular business models post-COVID.  Turning to new ways of looking at how to regain diminished revenue and increase market share by leveraging the data that has been collected about their patients, combined with the insights that data is revealing, has led to a shift in the balance of power from the patient revolving around various healthcare providers to the patient being the center of the healthcare universe, around which their healthcare providers revolve to deliver coordinated, complementary care.  This foundational change in how providers perceive and treat their patients as a key recovery strategy post-COVID is gaining traction as they derive strategies to make the transition from traditional fee-for-service to value-based care models.

For decades, healthcare decision-making was based principally on a provider’s own records which were often in paper files and siloed across the various organizations that treated the same patients. But a paradigm shift is taking place, thanks to the power of technology, to better connect providers and patients in ways that produce more data-driven decision-making, better clinical outcomes, and greater patient satisfaction. Today we find ourselves in a watershed moment that could rightfully be called a digital health revolution as new technology platforms and smart devices continue to disrupt, in a positive sense, the way information is collected, the way healthcare is delivered, and the way consumers are able to personally interact with the healthcare system. As a result, emerging technologies have evolved from a “nice to have” to a “need to have.” Now that this fuse has been lit, all indications point to an ever-increasing acceleration of this movement in 2022 and beyond.

It is encouraging to see the healthcare ecosystem populated with an increasing array of marvelous innovations capable of efficiently performing many useful, previously resource-intensive functions. These solutions put our industry on a journey to even greater achievement while also providing visibility into how we can expect the digital healthcare engine to evolve in the near term. In this atmosphere of looking at old problems in new ways with more powerful tools, three truths have been revealed:

1. The best reporting tools look forward, not backward. Business leaders don’t adopt technology based on capabilities alone. They often select solutions based on the reporting and analytical insights they can gain and whether those insights translate to meaningful business intelligence. Reporting that looks forward and projects what “could” happen as delivery systems are incrementally adjusted based on what “did” happen, gives clarity to  a wide array of sectors within healthcare. In doing so, the shift to put the patient and what they want at the center of treatment decisions has become more mainstream and less innovation.

When the power of historical and current data is harnessed to reveal issues or barriers to increased productivity and higher patient satisfaction, those matters can be confronted in a timely manner by the organization before they snowball into large-scale problems. Monitoring patient trends using data available (but previously not actively used) to create insights across populations also allows healthcare organizations to track patient behaviors as part of anticipating how to increase utilization and satisfaction. This information helps tailor care to the individual which improves outcomes and reduces unwanted events. In short, effective reporting isn’t merely about understanding what has happened in the past but is also about providing the intelligence needed to move forward with confidence.

2. Healthcare leaders need unencumbered access to their data. If leaders are to optimize healthcare delivery and derive strategies to address the issues that hinder growth and increase revenue, they need the ability to benchmark the performance of specific processes and functions. Limiting access to data, whether intentional or unintentional, only impedes these improvements and weakens the organization as a whole. The right information analysis and understanding of the tools available allows healthcare professionals to spot weaknesses, identify strengths, and predict events before they occur.

Without access to these insights, management is unable to make timely, data-driven decisions or easily share information across organizations to support new patient-focused value-based care initiatives. That’s why comprehensive patient data tracking, reporting, and analytics tools are important tools to delivering actionable business intelligence.

3. Data must be integrated across care settings. The overarching goal of healthcare is to provide patients with interventions that render the best possible outcomes. This goal, however, is impeded when patient information resides in multiple locations and is not readily accessible as the patient receives care from multiple providers in various care settings. Transitions in care – between providers or across levels of care – are particularly vulnerable breaking points and serve to make the need for immediate access to information about the patient regardless of where care is delivered all the more critical.

Ensuring data privacy for the patient being served can further complicate the process of moving personal health information across the healthcare continuum, but fortunately interoperability standards are being embraced for seamless and secure data exchange and accessibility from one system to another. These standards give patients the opportunity to engage with their providers directly from remote locations or when due to illness or injury they can’t speak for themselves, allowing them to bridge provider knowledge gaps, information silos, and be more active participants in their care.

The ability to bring patient voice into the center of healthcare delivery is continuing to rise in demand as patients welcome the shift from being moved from one provider to another without the ability to impact the care they receive to being able to influence their own care across providers. One outstanding example of this is the increased attention being paid to advance care planning (ACP) and its rightful place in a digital world. An ACP document can assure patients that their own voice – not the “voice” of a hospital, employer, health plan, or any government – will be heard and used to inform the care they do or don’t desire. Documents such as an advance directive or an advance care plan empower people to express their priorities for quality of life and memorialize what makes life meaningful to them. ACP documents allow individuals to specify where they want to receive treatment – at home, or in a senior care setting or in a hospital, for example. And they provide the opportunity to share those preferences and priorities for their life and healthcare decisions with their advocates and the medical teams who will ultimately make treatment decisions for them. Here, too, technology is playing a major role as digital platforms exist that allow for ACP documents and portable medical orders such as DNR orders and POLST forms to be easily created by patients or providers in a streamlined approach, securely stored and, most importantly, made accessible to family, caregivers, and healthcare providers 24 hours a day, 7 days a week, every day of the year.

This is indeed an exciting time in healthcare as the appetite for innovations in technology and the use of data to create new insights to change healthcare delivery models are moving the patient to the center of care and creating a more personalized and responsive delivery system. As the Copernican Shift continues to evolve, healthcare organizations and providers will continue to embrace new tools and analytics as part of a truly connected healthcare ecosystem. I'm excited to see what the future will bring!

Maria D. Moen is Senior Vice President of Innovation & External Affairs at ADVault, Inc., the nation’s leader in digital advance care planning solutions. Its end-to-end, cloud-based, SaaS solutions empower patients to create, store, and share their ACP documents in a secure, protected platform.  ADVault also enables healthcare providers to manage their ACP activity and supports providers’ creation, update, storage of their patients’ healthcare wishes in a secure, electronic registry and repository that can be accessed by medical teams anytime, anywhere. http://www.advaultinc.com/  

Scaling the Mountain of Pain Management: Why Virtual Reality is the New Pathway

By Gerry Stanley, M.D. , May 5, 2022

There may be many ways to summit Mount Everest, but the safest route is to follow an established path with the help of a seasoned guide. The same advice holds true for exploring the latest and most promising innovation for treating patients suffering from chronic and acute pain: virtual reality.  

Published Results for Vx(R) Therapy

The combination of virtual reality and behavioral health is a novel and effective option for resolving pain in the workplace, according to results of an article published on October 16, 2021, in the peer-reviewed journal "Pain and Therapy." Study authors included myself, Chief Medical Officer, Harvard MedTech; A. Abd-Elsayed, Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin; and N. Hussain, Department of Pain Medicine, Beth Israel, Deaconess Medical Center, Harvard Medical Center.

The results reported in "Pain and Therapy" were achieved with a cohort of adult workers' compensation patients aged 18 – 65 who were treated for acute or chronic workplace injuries from April 2019 to April 2020. All patients were referred to and overseen by a prescribing physician and referred to the Harvard MedTech Vx Pain Relief Program by orthopedic specialists, pain specialists, primary care physicians and occupational health providers.

Patients considerably reduced mean pain scores each week, averaging a reduction of 40% while using the virtual reality headset. In addition, their mean daily time spent thinking about pain symptoms decreased from 9.78 hours at the start of therapy to 2.76 hours after completing the 12-week program, representing a 72% reduction.

69% of Vx Patients Reported Decrease in Opioid Use

Reduction in reliance on opioids for pain control was also recorded, with 69% of patients reporting decreased opioid use. Patients experienced a 115% increase in their sleep duration and a 280% increase in the subjective quality of their sleep. Little attention is paid to sleep architecture and sleep hygiene in the workers' compensation field. But when patients report that they are doubling the number of hours they are sleeping, it naturally translates into an environment where their depression, anxiety, PTSD and pain will improve, not to mention the underlying physical ailment driving their workplace injury.

As a result of these findings, we concluded that the Vx program - combining VR Therapy plus counseling - appears to provide meaningful reductions in pain and opioid use while improving the psychosocial aspects of trauma and pain, such as sleep, behavior, and physical activity.

Why Virtual Reality by Itself Isn't Enough 

Virtual reality has been explored for health care purposes for decades. Three factors are making it so impactful now:

Consider the mindset of a typical injured worker, someone who is depressed and isolated and removed from their familiar world. Imagine if you could allow that injured worker to disappear into a virtual world. They could leap down the rabbit hole for situational relief but not develop the skills necessary to achieve long-term healing. Combining that powerful escape mechanism with the guidance provided by a behavioral health specialist allows the patient to traverse their injury - both physical and psychological- without getting lost down the rabbit hole.

Moving Beyond Drugs and Surgery

Until now, the primary way to treat people with chronic pain or the effects of trauma was to use a biologically focused regimen of drugs, surgery, or a combination of both. Now we understand that targeted therapy using virtual reality and customized coaching can help the brain override the experience of pain, anxiety, and depression, without the potential dangers of drugs or surgery. 

The impact of the virtual reality experience is supported by the Gate Control Theory of pain, which posits that alternative stimuli can reduce the intensity of physical pain by blocking pain messages at nerve gates in the spinal cord. 

In essence, Vx Therapy has the ability to reprioritize the signals we are processing in our brains to promote long-term resiliency in patients.

Who Pays for This New Therapy? 

As with any breakthrough solution, payment for these services is key to widespread adoption. Reimbursement for Vx Therapy is expanding among payers who recognize its value, especially when comparing it to the cost of prescription drug addiction, ongoing and even lifetime treatment, and/or additional surgeries that may not work. It's especially gaining traction within workers' compensation, where most injuries involve pain that, left untreated, can become long-term and expensive cases. It is important that a physician and or medical group partners with an experienced Vx provider who can work with them to ensure appropriate coding and reimbursement.

A New Model for Workplace Trauma

The combination of virtual reality and behavioral coaching within the Vx Therapy model activates the bio-psycho-social model for healthcare, first described by Dr. George Engle in 1977. So much of modern healthcare is focused on the biologic or physical aspects of disease. Now, the confluence of guided technology with behavioral coaching allows clinicians to engage and address the patient's underlying psychologic and social factors.  

The timing of this solution corresponds to the growing awareness of the role of behavioral health and recovery. The Orthopedic Forum recently published an article trying to understand and address the psychosocial determinants of health that derail orthopedic procedures. Many medical groups are trying to address this very topic. Vx Therapy has leaped to the forefront as a useful tool in addressing these silent aspects of patient care.

About the Author:  Gerry Stanley, M.D., is Senior Vice President and Chief Medical Officer for Harvard MedTech. For more information, visit www.Harvardmedtech.com.

We Love Innovation. Don’t We?

By Kim Bellard, April 22, 2022

America loves innovation. We prize creativity. We honor inventors. We are the nation of Thomas Edison, Henry Ford, Jonas Salk, Steve Jobs, and Stephen Spielberg, to name a few luminaries. Our intellectual property protection for all that innovation is the envy of the world.

But, as it turns out, maybe not so much. If there’s any doubt, just look at our healthcare system.

Matt Richtel writes in The New York Times “We Have a Creativity Problem.” He reports on research from Katz, et. alia that analyzes not just what we say about creative people, but our implicit impressions and biases about them. Long story short, we may say people are creative but that doesn’t mean we like them or would want to hire them, and how creative we think they are depends on what they are creative about.

“People actually have strong associations between the concept of creativity and other negative associations like vomit and poison,” Jack Goncalo, a business professor at the University of Illinois at Urbana-Champaign and the lead author on the new study, told Mr. Richtel.

Vomit and poison?

Well, at least our patent system, which protects intellectual property and helps fosters innovation, works, right? Again, not so much. A New York Times editorial charges: “The United States Patent and Trademark Office is in dire need of reform.”

If there’s any doubt, just look at the price of insulin, which has been propped up by patent “innovations” that keep its price high after a hundred years. “When it comes to protecting a drug monopoly,” The Times says, not limiting those monopolies to insulin, “it seems no modification is too small.”

The U.S. is still, by far, the leader in patents granted, but not in scientific research papers or R&D spending per capita/% of GDP, which makes one wonder what all those patents are for.

Healthcare desperately needs innovation. No one can dispute that; not anyone working in it, not anyone receiving care from it, not anyone who has had any exposure to it. But healthcare also has a lot of middle managers, and middlemen, and, as Professor Mueller said, “Novel ideas have almost no upside for a middle manager.”

Even worse, healthcare is always teetering on the edge of uncertainty — where’s the funding coming from, how much, what health crisis is coming, what’s the government going to do next? The forces causing all that uncertainty should be driving innovation, but, as Professor Morrison’s 2012 research also found, “…uncertainty also makes us less able to recognize creativity.” We have blind spots about what creativity is, who creative people are, and when and how we should incorporate those into our organizations.

Right now, healthcare thinks that EHRs and digital health — whatever that might actually be — qualify as innovation. That’s enough, it believes; those are forcing change in ways and at a pace healthcare is not used to and is not comfortable with.

Too bad.

It has been said that if your company has an innovation department, it’s not innovative. If it has middle managers deciding which novel ideas get pursued, don’t expect real innovation. If it is ruling out hiring people who worked on unusual projects (think sex toys), it’s rejecting creativity.

Your biases against creativity may (not) be showing.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)  

Value-Based Care and Care Coordination: Five Key Takeaways from WakeMed Key Community Care and UC San Diego Health

By Claire Thayer, April 12, 2022

Healthcare organizations face increasing pressures to meet demands of population health and effective care management.  Recently, we hosted a panel discussion webinar, co-sponsored by MCG Health, that identified some of the challenges to delivering value-based care and how providers are leveraging MCG Health solutions for care coordination to develop high-quality care programs.

We caught up with speakers Lindsey Pierce, MSN, RN, CCN, Assistant Director, Population Health UC San Diego Health and Kathryn Tarquini, PhD, RN, CCM, Director, Clinical Services, WakeMed Key Community Care on five key takeaways:

1. How did COVID-19 impact your organizations?

According to the CDC, an estimated 41% of US adults with one underlying medical condition avoided seeking care in 2020. This number jumps to over 50% for people with two of more underlying medical conditions. The COVID-19 pandemic is at least partly to blame for these gaps.

Lindsey Pierce: During the pandemic, we saw that patients were either delaying care or switching over to telehealth visits, and they weren't being screened as adequately. Patients were also very scared and often socially isolated, so there was a further need to use MCG psychosocial assessments to address these new gaps. Like so many organizations, we also had issues with staffing. Nursing students were unable to graduate at a time when we needed nurses, so we took a twofold approach, and we started a nursing student clinical program with our population health team who contacted patients during this time.

Amid the pandemic, we were also starting new programs and making changes to better serve our patients, and it was difficult to get everyone aligned around the needed cultural change. This is something that takes time and it's important to remember to communicate the ‘why’ behind value-based care and make sure that your team understands it. Starting out, it took a little bit of time even for providers to understand that our care managers are part of the care team and we're here to help them. Using physician champions and patient advocates helped to break down those barriers, build rapport across the teams, and now every provider wants our team involved in the patient’s care.

Kathryn Tarquini: One of the challenges we faced was launching a renewed service line - new teams, models, platforms, and tools - in early 2020, alongside the start of a pandemic. We learned to leverage our strong foundation built on the mission and vision of the ACO and the care management model. This meant we had to learn to engage virtually and build and strengthen relationships that way, using multimodal messaging to educate partners and providers about our service lines.

We also listened to what providers and practices were experiencing and needed, especially around the pandemic with things like vaccinations and other care interventions so we could provide solutions to address them when possible. Our technology platform and tools allow for transparency of our care management work, which also helped.

2. How is the transition to value-based care affecting your organization?

Lindsey Pierce: Overall the transition to value-based care has been a tremendously positive impact for UC San Diego Health (UCSD). It's allowed us to help drive some cultural changes that really benefit our patients, and it also gives us the opportunity to generate some revenue or share savings. We found that population health services have been at the forefront for helping to drive cultural change in strategy for value-based care, and we see that for interdisciplinary teams risk stratification and utilization oversight are essential to the success of the care program.

We began in 2016 as the organization started to shift towards growing our value-based contracts. We started in Medicare Shared Savings about three years ago and it helped us to expand and grow our network within San Diego, and we now have around 60% of insured lives under a value-based care arrangement. Before this shift, UCSD was performing significantly higher than the national average on hospital admissions per thousand. Over our three-year journey of aligning workflows, integrating technology, and improving processes, we’ve really been able to bring down avoidable hospital admissions to considerably below the national average.

For organizations who are starting out on this journey, it can seem like a difficult transition going from fee-for-service to value-based care. But at its core value-based care is simple, it's quality divided by cost, and this helps support high quality and cost effective care delivery. Through our population health services, we’re able to provide wrap around services to our patients and that helps us to support high quality of care. I do think we'll see this more in the future in healthcare in the coming years and it’s something that I'm excited to be a part of.

Kathryn Tarquini: WakeMed Key Community Care is an ACO formed in 2014 as a joint venture between WakeMed Health and Hospitals and the Key Physicians Group of independent physicians in the Raleigh, North Carolina area. These organizations came together because they realized the importance of delivering high quality care in a value-based care model. Since the ACO was formed eight years ago, our primary care physicians have come to understand the value of value-based care. They’re now highly experienced and have become strong advocates for this model. In 2020, we brought all population health services in-house and this resulted in the formation of new centralized teams for care management – which is when we began using MCG and Arcadia for our care management needs. This has also helped us to provide higher quality care. The overall effect on the organization is based on the results that we’ve seen in quality, achieving and exceeding quality measures, being able to provide coordinated care, and using tools to proactively care for patients. Currently, there are also a variety of population health and quality initiatives within many departments of the hospital system that are value-based, such as hospital or home and navigator programs. We're working together to align some of these initiatives and connect the leaders to more formally collaborate and create some synergy for greater success. 

3. What role have your technology partners played in supporting your transition to value-based care?

Kathryn Tarquini: Our primary partners that have made our program successful are MCG and Arcadia. These two partners have been critical to creating a strong foundation, and there's a lot of synergy that comes from the alignment and integration of these two. We use MCG guidelines for clinical decision support integrated into Arcadia’s Care management platform to document, track, and manage the care management work and the care managers’ workload – this is at the core of what we do with care management.

Arcadia also provides for our data analytics and management system and allows for data exchange with each other. We have close to 20 different EMRs in our ACO and so it collects and exchanges data with the EMRs to provide proactive tools. For example, a pre-visit planning tool to proactively manage risk and a predictive analytics tool using data from claims, the EMR and census data to identify those patients who are most likely to benefit from care management. The Arcadia platform also provides a way to see the status of quality measures – specifically which quality measures are completed and which ones have a gap – so that the practices can proactively address those by reaching out to patients. It promotes care coordination with the providers and the practice partners by allowing all members of the health care team to view all aspects of the care management process in real time.

The partnership with MCG supports the team with accurate and efficient assessment tools that are easy to read and follow, written in a conversational tone, and with many evidence-based assessment options to choose from. Using MCG also allows us to have standard work at the point of care, and this is especially helpful for our team with diverse experience and expertise. We have a multidisciplinary team of RNs and LCSWs, and what we call case management representatives. Using MCG ensures that everyone is deploying the evidence-based guidelines consistently, which leads to an efficient workflow and positive work experience. 

Lindsey Pierce: It’s important to have partners that understand your organization’s vision and provide tools that allow the team to be organized, efficient and perform at the top of their clinical license. In 2021, we integrated MCG care guidelines into Epic Healthy Planet, and our team was involved from the very beginning. We had super users to make sure that the product worked efficiently. We also have health coaching through text message and remote blood pressure monitoring, so we've created really nice wrap around service for our patients.

With MCG’s partnership, we refined and made sure the workflows were seamless, and it was great from a patient perspective as well. It was an absolute journey, but one of the things we always look for, whether it's the community partner and affiliated provider or vendor, it's making sure that you have a partner who's willing to work with you and reach the ultimate goal and is willing to adapt and change - in healthcare you have to be adaptable and willing to adjust as needed. We found that really great partnership with MCG. We got help and support every step of the way with our Epic super users and from our team who were working on integrating the assessments. In 2024, we're hoping to get population health accredited through NCQA, and I think that will be very well supported based upon the integration of MCG’s assessments. Our text-based health coaching platform also uses MCG’s education materials, so that's fantastic because the patients are hearing the same information consistently whether it's through the text messaging program or if we mail our educational materials. Building strategic partnerships with community organizations, network-affiliated providers, or vendors, it's really important that all are aligned to avoid duplication of services, waste, and coordinate a really seamless experience for our patients. That's something that we've certainly found through the relationships that we've developed with MCG and our other partners.

4. In what ways has predictive analytics helped your organization to improve patient outcomes?

Lindsey Pierce: It’s important to have data analytics that identifies gaps in care opportunities, performs risk stratification and identifies patients most likely to benefit from the program, and turns patient clinical data into actionable information. I think oftentimes as we enter into more value-based care contracts, each will have nuances of the data analytics they're looking for. If you can synthesize down to one overarching goal, this can help to simplify a target for your care team, and that way your team members and providers aren't feeling confused about what they're working towards. We've done that with UC San Diego Health - simplified to just a few simple goals - and we apply them to all of our value-based care agreements and our team is really clear on what we're working towards. They're easy to measure, and it gives us a good place to work on process improvement. We focus primarily on one goal that's lowering all costs: hospital admissions per thousand. We do this because it's very well-defined, easy to measure, and is a metric where our team can make a direct impact. There might be some goals that you maybe don't have great data analytics on; even though it might be a good goal, if you can't share the outcomes, that can make that goal really difficult to work towards.

Kathryn Tarquini: We use data analytics in real-time and just-in-time opportunities to optimize care and proactively manage risk to drive population health management, and predict which patients are most likely to benefit from care management services. One tool that our practices use is the ‘pre-visit planning tool,’ which helps the care team identify quality care gaps and risk coding opportunities just before an office visit. So far, this has helped us achieve exceptional quality scores and lower readmission rates across numerous payers, and we’ve been able to distribute shared savings to participating providers each year. For example, between 2016 and 2019, we distributed nearly $120 million in shared savings from BCBSNC contracts alone.

5. What are some of the major milestones, key players, and successes you’ve seen implementing enterprise-wide value-based care model?

Lindsey Pierce: Key milestones were the development of our community network (community partnerships), growing our team and getting our workflows to be standards-based, along with integration with telemedicine to extend our reach without adding FTEs. We needed involvement from every level, physician champions, leadership, great vendors that can address gaps, and care managers. We found that having solid relationships with our network is one of the first steps we needed to take, and it was really important for us to regularly meet and facilitate goal alignment with that network. That way we were able to share performance milestones and make sure that every provider within the network understood the benefits and also the potential risk. We really focus on having our care team members work to the top of their licensed scope of practice and we also want to give them the tools to have a direct impact on process improvement for our team. We sent them all to LEAN 6 Sigma training and this just helps the team to understand the tools and resources on how to create change as you work towards standardized work in a new program. We joke all the time on our team that the only thing that's consistent is change because we're continually refining our workflows to be lean and patient-centered.

Kathryn Tarquini: There are two main factors that contribute to our success. The first is our providers, and the fact that we’re a physician-led ACO. Our providers are experienced advocates for value-based care – and we have strong relationships with them and their practices. Our model places the patient/PCP relationship at the core of our work. Providers review patients who've been identified for care management by our predictive analytics, and when possible, they alert patients of our pending outreach.

Another factor contributing to our success is the compassionate and highly-skilled care management team we’ve assembled. We help them have a positive experience, professional fulfillment, and joy through this work by equipping them with MCG and other tools, educating them about strategies, skills and trends, and we problem-solve together. By creating a work environment that focuses on continuous quality improvement, fosters collaboration and innovation, and where it's safe to learn and grow from opportunities, we’re able to fulfill our mission and deliver timely, high-quality care to our patients.

We've been seeing upwards of 50-70% engagement with patients through care management, and we have numerous patient stories demonstrating how the team has been able to make a difference in our patients’ lives. We decided last year to reinvest shared savings to provide actual solutions to identify social determinants of health (SDOH)-related barriers. We've been excited to launch two initiatives this year, including a rideshare for transportation support, and a meal service for delivering medically-tailored meals to patients’ homes. We are really looking forward to seeing some of the specific examples and impact that these and other interventions are having on our patients’ health and their health outcomes.

If you missed this informative webinar, we invite you to watch this short recap video here. Additionally, below is a list of webinar supplemental material that may interest you: 

MCG White Paper. Populations at Risk: Optimizing Post-Acute Care Management

On-Demand Physician Leader Webinar Series. Populations at Risk: Optimizing Post-Acute Care Management

MCG White Paper. Population Health: Engaging Patients to Improve Healthcare Outcomes

The MCG Guide to Efficient Care Coordination & Patient Throughput

Catching up with Advisory Board’s Ken Leonczyk on the State of the Health Plan Industry and what health plan leaders need to know for 2022

By Claire Thayer, April 11, 2022

The pandemic has had a significant impact on health plans and in many ways has been a catalyst for change across the healthcare industry. Recently, Ken Leonczyk, Executive Partner, Advisory joined us for a lively discussion on what health plans need to know about key structural shifts of the peri-pandemic period. Ken identifies these six strategic points of inflection that will shift industry structure in the years ahead.

Value-Based Payment

Risk-based payment models will continue to grow, but who participates is an open question. The pandemic has done little to shift long-standing barriers in hospital financial needs, but plans have made headway with independent physician groups. Plans must now think about how the growing array of models fit together in a complex ecosystem.

Physician Alignment

An array of non-hospital suitors—plans, private equity firms, service partners, and national groups—are aligning more closely with physicians through a variety of partnership models. While hospitals may lose power, plans need to prepare to navigate relationships with all manner of new stakeholders throughout physician networks.

Home-Based Care

The wave of investment in home-based care today, centered around start-up financing or grants, does not guarantee long-term, systemic change. The industry may exacerbate existing challenges around staffing supply, care fragmentation, and health inequities. Plans must weigh how their policies will impact network access and marginalized patients.

Virtual Care

Most of the pandemic’s spike in virtual care came from traditional providers, but vendors are angling to transform their offerings to steal patient relationships— not just visits. As plans explore virtual-first products, they must ensure incentives are enough to influence consumers—and brace for fallout with local providers.

Price Transparency

The market will soon be inundated with an unprecedented level of pricing information, but disruption to historic practices will depend on the usability of the data. New vendors are emerging to parse and package the data for end users, so plans must prepare to clarify the broader context of their rates to members, purchasers, and providers.

Health Equity

The past few years brought health equity into stark focus, but to make true progress, leaders must cement equity as a business goal. As plans build equity goals into provider payments and care management actions, they must standardize data collection and analysis to generate evidence for sustainable interventions.

If you missed this informative webinar presentation, State of the Health Plan Industry: Unpacking the potential impact for 2022 planning, we invite you to watch this short webinar recap video here.

You can access the complimentary presentation slides presentation slides here and webinar video here.   To continue the conversation with Ken Leonczyk and learn more about how Advisory Board is working with other health care organizations, drop him an email at healthplan@advisory.com.

Spring is Here and Medicare Advantage is in Full Bloom

MCOL Staff, April 7, 2022

Mark Farrah Associates has released their assessment of Medicare Advantage  and Prescription Drug Plan  performance, market share and market penetration as of March, 2022. They report that total MA membership exceeded 29.4 million and Medicare stand-alone PDPs covered over 23.4 million members. Year-over-year MA plan enrollment grew by 8.5%, and PDPs experienced a membership decrease of -3.4%.

MFA tells us that:

• Texas experienced the most sizeable year-over-year increase of over 172,000 MA members.
• Stand-alone PDPs continued to see a significant decrease of approximately 824,000 enrollees between March 1, 2021 and March 1, 2022.
• CVS, Centene, UnitedHealth, Humana and Cigna were the top five companies that dominate 88.5% of the PDP market.

MFA reports that In the MA world, UnitedHealth in March 2022 holds the top position with 27.1% marketshare, followed by Humana with 17.4%, CVS Health with 10.7%, Anthem with 6.5% and Kaiser with 6.1%.

Also, here’s the March 2022 MA/PDP Snapshot recently released by MCOL in HealthExecSnapshot:

Strategic Prioritization and Deselection: Being transformative in the beginning stages of an endemic

By Dr. Seleem R. Choudhury, March 31, 2022

On the cusp of entering an endemic state, organizations are deciding what to turn their attention to “after COVID.” Wise leaders will recognize that this is not as simple as carrying on with their pre-COVID strategies. No organization has been immune to the shockwave of disruption that the pandemic has caused (Lagasse, 2020). This is especially true in the healthcare field. Hospital staff and resources are strained from bearing the weight of pandemic changes and regulations as well as the loss of skilled staff in the Great Resignation. You simply cannot “pick up where you left off” strategically when your workforce—the essential piece to actually accomplishing any strategy—is burned out and struggling. Something has to give. 

Traditionally, at the beginning of a strategic planning activity, the organization establishes a vision focusing on the desired future state. This future state is usually based upon understanding the current state, forecasting, and looking for opportunities to excel among a playing field that is familiar. Yet today, the healthcare, business, chain supply, workforce, economic, governmental, state, and regulatory landscape is far from familiar. The past two years have been an extended “strategic resilience test” of sorts (Diedrich, Northcote, Röder, & Sauer-Sidor, 2021). While all organizations understand the importance of strategic planning and implementation, only those with high levels of situational awareness will thrive post-COVID.  Put simply, situational awareness is “knowing exactly who you are, where you are, where you are going, and how you will get there, within your rapidly changing environment” (Afterburner Team, 2022).

Situational awareness requires a dynamic review not just of your strengths as an organization, but your limitations within the current environment. In healthcare, a years-long pandemic and a decimated and tired workforce presents organizational limitations that demand organizations to rethink their old, all-ambitious strategic plan that requires numerous detailed sub-plans, resources, funding, and metrics. Instead, the strategic plan needs to be narrowed, unifying, well-paced, and focused. Today, the biggest strategic decision for healthcare institutions will require boldness, but it isn’t about doing something new. Rather, it is about doing something less.

“Strategic deselection”

The landscape we find ourselves in is unfamiliar. While healthcare organizations could push through and aim to succeed in their myriad pre-pandemic priorities, this transition period from pandemic to endemic is an opportunity to consider what would be most advantageous to focus on, what needs to be done and what does not.  This is an opportunity to prioritize and deselect, rather than to add.

Sg2, a healthcare consultancy company that focuses on healthcare trends and unique solutions, states:

“The ability to prioritize the most impactful initiatives the organization is positioned to execute over the short-term, while simultaneously deselecting those that could derail it, will be essential to ensure sustainability” (Sg2, 2018).

Often organizations do not have the ability to or see the benefit of pausing existing initiatives. A lack of “sunset” processes in many organizations make it difficult to determine when to retire a strategic plan  (Hollister & Watkins, 2018)ollH. Deselection is about triaging the strategic plan, understanding that all tasks cannot possibly be saved based on existing capacity. This requires leadership willing to make difficult decisions about what needs to be discarded or paused to give only the top priority their full attention. A focus on only one to three key priorities will allow the organization to use limited resources well, and will give staff a chance to recharge by being attentive to and report on only a small number of priorities.

Define criteria for selection and deselection

It is normal behavior for organizations to focus more on what they need to do than the things they have already accomplished. This is called the “Zeigarnik effect.” Psychologists describe it as a “psychological phenomenon describing a tendency to remember interrupted or incomplete tasks or events more easily than tasks that have been completed” (Good Therapy, 2016).

There are multiple tools and strategies that can help organizations overcome this tendency in order to have laser-like focus on only their most essential goals. A simple tool to aid strategic prioritization and deselection is a matrix. This tool can help an organization narrow their options “by systematically comparing choices through the selection, weighing, and application of criteria” (Public Health Foundation, 2022).

A prioritization matrix is often used with Six Sigma, and the above prioritization matrix breaks tasks out into two dimensions: “Do Now” and “Do Later,” and “Crucial” and “Not Crucial.” The matrix, once completed, can help illuminate what should be done, delayed, and deselected. Though simple in form, using the prioritization matrix effectively is hard work, requiring organizations to make difficult trade-offs and stop initiatives that were once enthusiastic about.

Stephen Covey is celebrated for his famous business quote: “The main thing is to keep the main thing the main thing” (Kruse, 2012). The concept sounds simple, but any leader knows that it is easier said than done. For an organization and its leaders, keeping in mind what strategies are primary, secondary, and which priorities rank lowest will help promote unity and confidence in decision-making (Rodenhizer, 2016).

Successful strategic implementation processes require the work and attention of employees and managers at all levels within a healthcare organization. The workforce is the main driver for implementation of strategy. Common business wisdom states that the more projects you do the less effective you become. “Staggering or postponing strategic imperatives” will reduce the number of projects handled at once, which effectively reduces the “number of projects per person” (Steyn, & Schnetler, 2015). Today, as healthcare organizations revisit their strategies, initiatives that include unlimited projects, ambitious milestones, and metrics success should be used judiciously, especially in the context of a distressed workforce.

Overload can result in “costly productivity and quality problems and employee burnout” (Hollister, & Watkins, 2018). Waves of healthcare and hospital workers have quit their jobs (or their entire profession) because of moral distress, exhaustion, compensation, poor treatment by their hospitals or patients, or some combination of these. These losses leave the remaining healthcare workers with “fewer trusted colleagues who speak in the same shorthand, less expertise to draw from, and more work” (Yong, 2022). It is critical for the health of our employees, and thereby the health of our organizations, that more strategies are minimized or deselected, and only the absolute necessities receive prioritization to move the organization forward.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com

Resources:

Afterburner Team (2022). Three Ways to Improve Your Situational Awareness. Afterburner.

Diedrich, D., Northcote, N., Röder, T., & Sauer-Sidor, K. (2021). Strategic resilience during the COVID-19 crisis. McKinsey and Co.

Good Therapy (2016). Zeigarnik Effect. Good Therapy.

Hollister, R., & Watkins, M. (2018). Too Many Projects. Harvard Business Review. September–October 2018, 64–71.

Kruse, K. (2012). Stephen Covey: 10 Quotes That Can Change Your Life. Forbes.

Lagasse, J. (2020). COVID-19 is forcing rural hospitals to rethink their business models. Healthcare Finance News.

Public Health Foundation (2022). Prioritization matrix. Minnesota Department of Health.

Rodenhizer, S. (2016). The Main Thing Is to Keep the Main Thing the Main Thing. Quotation Celebration.

Sg2 (2018). Transformative Planning: Strategic Prioritization and Deselection. Sg2.

Steyn, H., & Schnetler, R. (2015). Concurrent projects: How many can you handle?. South African Journal of Industrial Engineering, 26(3), 96-109.

Yong, E. (2022). Hospitals Are in Serious Trouble. The Atlantic.

ARPA-H Needs to Think Bigger

By Kim Bellard, March 25, 2022

Everyone loves DARPA, the Defense Advanced Research Projects Agency that is credited with such hits as the internet and GPS, but is also responsible for things like the Boston Dynamics back-flipping robots and even Siri.  

Healthcare is, at long last, getting its own DARPA, with ARPA-H (Advanced Research Project Agency for Health).  It’s been discussed for years, but just last week was finally funded; a billion dollars over three years.  But I fear it is already off on the wrong foot, even ignoring the fact that President Biden had requested $6.5b. 

Let’s start with the problem that it not only doesn’t have a leader yet, but it doesn’t even have a home.  More worrisome, though, is that, according to President Biden, “ARPA-H will have a singular purpose: to drive breakthroughs in biomedicine.”   The mission wasn’t originally that limited, but priorities like the “cancer moonshot” tend to focus emphasis. Biomedicine isn’t going to solve all of our health and healthcare problems.

Take, for example, the developing fiasco that is the replacement VA EHR.  Decades ago the VA developed VistA, one of the first attempts at an EHR, but during the Trump Administration it was decided to move to a commercial EHR.  Cerner won the bid.  According to three reports issued by the VA Inspector General last week about the first implementation, it is not going well, to say the least. 

Now, I’m not intending to pick on Cerner – its DoD EHR rollout seems to be doing better – or advocating for VistA. I don’t want ARPH-A to help invent a new and improved EHR.  I want them to help invent the technology that is to EHRs as EHRs are to paper records.  I want a big leap.

I want the next generation of health information technology, allowing people to store, share, exchange, and use key health information, making all that look easy – like magic.  I want technology that may not become mainstream until 2050, but which would still be useful in 2100.

I don’t know what technologies will be important to that. Maybe holograms, maybe digital twins, maybe DNA storage, maybe blockchain/Web3, maybe AI, maybe quantum computing.  Maybe all of those, and others.  The important thing is, think big enough.  About this problem, and others.

We should be looking at breakthrough technologies that get at health in our everyday lives.  How do we track it, how do we foster it, how do we improve it where we live?    Those are the kinds of thing ARPA-H needs to help develop.

DARPA’s projects can take 20-25 years to reach commercial viability – if they ever do.  We can’t afford to think too short-term (e.g., anything less than 10-15 years) or too narrowly (e.g., only biomedicine). When we think about ARPA-H projects, we should thus be thinking about what we want to our health and our healthcare system to be in 2050. 

I hope the VA EHR recovers from its stumbles.  But wishing and hoping isn’t getting us where we need to be; we need breakthroughs. 

Based on DARPA’s experience, it’s not important that the leader be a visionary.  We don’t need a Steve Jobs or Elon Musk.  We need a leader who can separate the crazy from the wild, who welcomes that wild, and who knows how to get out of the way of innovators trying to make the wild plausible.   

If what we’re debating is whether ARPA-H should be in or out of NIH, we’ve missed the point.  If we’re focusing ARPA-H on biomedicine, we’re missing the opportunities.  If we’re just trying to avoid more catastrophic failures, we’re having one.

Think bigger.  

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)  

The Continuing Relevance and State of Medigap Plans

By Clive Riddle, March 18, 2022

With such focus in Medicare-World on Medicare Advantage plans, its easy to forget that the continuing relevance of Medigap plans. While there are close to 24 million covered in MA plans, another 14.4 million have Medigap coverage.

AHIP’s Center for Policy Research  has just released a new report: The State of Medicare Supplement Coverage, which examines trends in Medicare Supplement insurance and discussed the financial value these plans offer to seniors and people with disabilities.

Their report found:

• Among original Medicare enrollees without additional insurance coverage (such as Medicaid, employer-provided insurance, etc.), 53% chose Medicare Supplement coverage in 2020.
• Between December 2017 and December 2020, the share of original Medicare beneficiaries who purchase Medicare Supplement coverage increased from 35% to 39%.
• However, in the first pandemic year, national Medicare Supplement 2020 enrollment was 14,395,788 (decreasing by 87,000, or -0.6%). This is in contrast with the consistent rate of growth of 3-4% observed in the three previous years.
• Medicare enrollees with Medicare Supplement coverage were 3 times less likely to have problems paying medical bills compared to enrollees without Medicare Supplement policies. Only 4% of enrollees with Medicare Supplement coverage reported having difficulty paying medical bills in the last 12 months, compared to 12% of FFS Medicare enrollees without Medicare Supplement coverage.
• Medigap coverage skews female – at 58%, which is explained at least in part by women’s longevity compared to men. 40% of Medicare Supplement enrollees were widowed, divorced, separated, or never married.
• A significant number of Medicare Supplement policyholders were individuals with lower incomes: 11% had annual household incomes below $20,000 and 26% had incomes below $30,000. This pattern was more widespread in rural areas, where 17% of Medicare Supplement policyholders had incomes below $20,000

The sources for the 2022 report are the 2020 National Association of Insurance Commissioners (NAIC) data, 2020 California Department of Managed Health Care data, and 2019 Medicare Current Beneficiary Survey (MCBS) results.

Google’s Alphabet, Facebook’s Meta, and now Anthem’s Elevance

By Clive Riddle, March 10, 2022

In 2015 Google unveiled Alphabet, a new name to brand the parent holding company separate from the Google identity. Last year, Facebook announced Meta in a similar fashion.  And now, 2,306 miles from Silicon Valley, an announcement emerges from Indianapolis that the separate parent name above the Anthem brand will become Elevance Health. Their announcement states that “the new name underscores the company’s commitment to elevating whole health and advancing health beyond healthcare.”

Anthem President and CEO Gail Boudreaux says the new name reflects “our transformation from a health benefits organization to a lifetime, trusted health partner.” Aetna in 2018 also shed the parent branding identity of a health benefits organization out of necessity, being acquired by CVS Health. While Cigna’s parent identity is still a health benefits organization - Cigna, their PBM Express Scripts acquisition in 2020 rolled up into Evernorth branding with new and existing applicable sister health service solution businesses. Last year Humana – like Cigna still sticking to parent health benefits organization branding – introduced CenterWell as the new brand for a range of its payer-agnostic health care services offerings. Not that this is a brand new concept in the health benefits organization world – UnitedHealth Group announced its "Optum" master brand for its health services businesses in 2011.

In their announcement, Anthem states its “family of companies has evolved to offer products and services beyond traditional health insurance. Through its digital capabilities, pharmacy, behavioral, clinical and complex care assets the company is able to address consumers’ full range of needs with an integrated, whole-person approach. It’s through these diverse assets that the company will deliver on its strategy, drive growth and exceed expectations for consumers.”

And their branding makeover won’t stop there. Anthem tells us that “the corporate rebranding is a first step in the company’s effort to optimize its brand portfolio. While Anthem Blue Cross Blue Shield health plans’ names will not change, the company does expect to streamline the number of other brands in the market to reduce complexities and improve consumer experiences.”

The company does more details in the form of FAQs in their new one-page website: https://www.elevancehealth.com/

What’s Next for Medicare Advantage: Part II - Next Up: Time To Get Real

by Lindsay Resnick, March 2, 2022

The is Part II of What’s Next for Medicare Advantage, offering a few observations and insights from the 2021-22 Annual Enrollment Period. The previous post, Part I - Frontline: Lessons Learned is available here.

Whether called ‘keys to success’ or ‘make it or break it time’ the following five challenges and opportunities are real. To be competitive in tomorrow’s Medicare Advantage marketplace plans need strategies for each.

Catch First-timers

On average 10,000 Americans turn 65 every day – THIS is Medicare Advantage’s new customer growth opportunity. While AEP will continue to be an important customer acquisition time of the year, fighting over fewer and fewer AEP switchers becomes a long, tough game to win. Individuals turning 65 choosing a Medicare plan for the first time and late market entrants (generally between ages 66 and 70) coming off an employer plan are the future of MA. For consumers, making the wrong Medicare insurance choice when they first enroll can not only be costly, but may mean they can’t get the best plan for them later. Plans with commercial Group and Individual business units have the extra advantage of capturing this ‘same brand’ existing customer cohort with an internal cross- over or cross-selling transition approach moving existing members to their Medicare products. Overall, the industry isn’t doing well here: only one-third of Medicare enrollees went to a plan with same group or individual carrier.

Grab consumers at their first Medicare enrollment decision, serve them well and plans can enjoy strong annual retention and profitable MA ROI. This is a year-round, always-on effort with significant LifeTime Value.

Leverage Retirement

The emotional charge around ‘retirement’ can be a persuasive response driver, supported by this eye-opening stat: A retired 65-year-old couple will need $300,000 for medical expenses…in addition to their Medicare coverage. Eighty percent of Americans age 65+ have a chronic condition and 68% have two or more. The link between retirement’s financial and healthcare concerns is extremely strong. In fact, one of the biggest post- retirement surprises cited by seniors is financial load of their Medicare coverage… I thought I planned for everything! Leveraging retirement planning into Medicare decision lead generation can be an effective direct response QOPC hook (Qualify, Offer, Product, Call-to-action). For example, ‘Take the Mystery Out of Retirement Planning‘ or ‘Financial Health in Retirement Depends on Your Medicare Choices‘ make compelling offers. Healthcare, long-term care and unexpected medical costs tops the list of retirement planning financial concerns...with both pre-retirees and retirees. It’s right up there with credit card debt, mortgage payments, savings, and Social Security.

Take the opportunity to speak with prospects at their “full” Social Security retirement: from 1943- 1954 it’s age 66, those between 1956-1959 its 66.4, and after 1960 full retirement age is 67.

Remove Friction

Again? Yes again…it’s time to deliver on high- performance customer experience/CX. Superior customer service goes a long, long way toward not only a top-level Star Rating, but it’s an essential part of customer retention and loyalty. Simply put: make sure the AEP switchers aren’t yours! Why pay the high price of acquiring new members just to see them walk out the back door? Investments in fixing and removing ‘points of friction’ throughout your MA plan, particularly inside your customer service organization, translate into improved profitability. And today, the bar is high. Even ‘satisfied’ customers walk out the door; ‘satisfactory’ performance is no longer enough to retain members---excellent, superior, first class and ‘the best’ need to be the plan’s goal. Once a plan has a ‘retention problem’ retroactively trying to keep members from leaving isn’t the answer. Rather, proactively delivering meaningful value and experiences that make members want to stay in the first place is a winning CX strategy.

CX represents an MA plan’s brand, it’s a marketable attribute that gets attention, and with recent adjustments to the new Star Rating guidance, having happy customers goes a long way.

Cultivate Partners

All the big retailers are in the Medicare game, either directly underwriting MA plans, selling plans through in-house agencies, or engaging MA customers through a branded primary care clinic or low-cost, convenience driven pharmacy service. During AEP these partnerships meant stores with high traffic area pop-up MA sales kiosks with agents and/or lead cards, co- branded Website tools and advertising, and pharmacist or clinic staff with “Ask Me About Medicare” buttons. For MA plans, it’s an if you can’t beat ‘em join ‘em moment to explore similar collaborative partnerships or joint ventures with national, regional, or local retailers. Collaboration is also being leveraged with providers. Either hospital systems or primary care physician networks sponsoring or affiliating with MA plans. Outside the strategic alignment that comes with this payer/provider relationship (aka Payvider), provider brand equity and trust can be a significant lead generation asset. Partnerships bring scale, which translates into financial and operating efficiencies, expanded market reach, and a better ability to address consumer demands for convenience, continuity, and consistency.

Teamwork makes the dreamwork. MA partnerships can yield big rewards: open new markets, extend product or service offering reach, and for consumers, better managed and more affordable health care.

Final Takeaway: Gut Check

The Medicare Payment Advisory Commission (MedPAC), a panel that makes recommendations to Congress on Medicare policy, expects beneficiaries in Parts A and B enrolled in MA plans to stretch past 50% in 2023.

Staying competitive in an increasingly benefit- rich, fast-paced growth market challenges even the best in the business. As Medicare Advantage plans strategize around their 2022 market moves, meaningful brand and product differentiation matter more than ever. On the marketing and sales frontlines, deploying the full power of distinction quickly separates winners from losers…those plans headed toward growth and profitability rather than a slow decline into obsolescence.

There’s no better time than the start of a new year to do a MA marketing ‘gut check’, an assessment to validate MA marketing assumptions, resource adequacy and comparative industry best-practice “gap analysis” to identify important areas of improvement. Here’s a 10-point checklist to guide your assessment:

Get Ready for (Healthcare) Microgrids

By Kim Bellard, February 24, 2022

We depend on it.  Indeed, our daily lives are unimaginable without it.  The trouble is, it’s become unreliable.  Lives have been lost because it wasn’t performing when it needed to be.  It’s built around large facilities that are often decades old.  Parts of it don’t communicate/coordinate well with others.  Its workforce is aging and burnt out.  There is no person or agency charged with ensuring its resiliency. It badly needs to be rethought for the 21st century. 

Oh, you thought I was talking about our nation’s power grid?  I was talking about our healthcare system. 

The parallels are striking, and concerning.  The power outages in Texas last year caught everyone’s attention.  People went for days or even weeks without power.  Oh, that’s Texas, people elsewhere might say, so the failures were not really surprising. Maybe, but it’s not just Texas.  

Large, sustained outages have occurred with increasing frequency in the U.S. over the past two decades, according to a Wall Street Journal review of federal data. In 2000, there were fewer than two dozen major disruptions, the data shows. In 2020, the number surpassed 180.

That’s where microgrids come in.

According to Microgrid Knowledge, a microgrid is a self-sufficient energy system that serves a discrete geographic footprint, such as a college campus, factory, hospital complex, business center, military installation or neighborhood. Microgrids can operate independently from the grid using power generated on-site; they can also be used for backup power. Microgrids are designed to operate consistently in both “blue sky” and emergency situations supported by a range of energy resources, such as renewable energy, energy storage, combined heat and power or generators.

Healthcare needs to literally join in.  If there’s a hospital, nursing home, pharmacy, dialysis center, or other health care facility that hasn’t already become part of a microgrid, it’s time.  Those 1960’s-era backup generators are not going to cut it.

Healthcare needs to figuratively join the microgrid movement.  Think of hospitals as the traditional power plants, the loci of the healthcare system.  Everything revolves around them, especially as they’ve bought physician practices, developed more outpatient facilities, and consolidated.  They control how healthcare is practiced and at what cost in their community/region. They power the system.

That’s worked for us, in our dysfunctional U.S. healthcare way, but the cracks are showing. We’re effectively seeing healthcare’s versions of brownouts, or even blackouts.  If there is one thing our healthcare system is not, it is resilient.

A healthcare microgrid would more effectively keep people out of hospitals.  It would rely less on physicians, especially specialists.  It would be community-based.  It would be available 24/7, and be able to flex capacity as needed.  It would be “smart,” and incorporate as many 21^st century technologies as possible, such as home monitoring.  Unlike actual microgrids (but more like most power grids) and unlike current medical practice, it would freely cross city/state/regional lines.

Telemedicine is an example of what should be included in microgrids.  Some hospitals are bold enough to impose facility fees for telehealth visits. Those are all signs that telehealth is not part of a microgrid; it’s being coopted by the power plants – er, hospitals.

Similarly, are we really taking advantage of nurse practitioners or physician assistants can do?  Why do we even think of nurse practitioners as “nurses” or PAs just as assisting physicians?  Do we give pharmacists as much authority as their training would allow for? 

And, of course, when are we going to get AI that can be our first line of medical advice, and perhaps more?

These are microgrid questions. They’re not questions we should only be considering during times of extreme crisis, like the current pandemic; they are questions we should be answering for the next crisis.   

The analogy is not perfect. I don’t know exactly what a healthcare microgrid would look like.  But, just as I know traditional power grids are not going to be enough for our energy needs, our traditional healthcare system is not going to be enough for our healthcare needs. We need something more resilient and more localized.  We need healthcare microgrids.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)  

What’s Next for Medicare Advantage: Part I - Frontline: Lessons Learned

By Lindsay Resnick, February 17, 2022

As its 20th anniversary quickly approaches, Medicare Advantage has surpassed 28 million members. 46% of eligible Medicare beneficiaries now choose an MA plan. The average Medicare beneficiary has access to over 40 plan options, many providing extra annual benefits valued at $2,000 compared to fee-for-service Medicare.

The top 25 Medicare Advantage insurers have almost 90% national market share. In a jam-packed marketplace dominated by mega-national plans and aggressive third-party aggregators. The battle for new members has never been tougher. And, while more than 3.5 million Americans turn 65 every year, they’re working longer, shifting retirement plans, reevaluating health and financial priorities, and unlike Medicare eligibles of yesteryear, this New-to-Medicare crowd has different motivations when it comes to their personal shopping and purchasing preferences.

Following are a few observations and insights from the 2021-22 Annual Enrollment Period.

National MA Plans

These industry giants leveraged outsized marketing and media spends to dominate consumer top-of-mind during AEP. From a constant TV presence to flooding mailboxes with direct mail to in-store sales kiosks at national retailers, these competitors crushed regional and local plans when it comes to advertising, both brand and direct response. Mega-national plans also proved to be adept at quick action on product enhancements and agent/broker engagement tactics that resulted solid lead generation and sales. The 6 largest MA plans claim stake to about 75% market share. In an analysis of large publicly traded MA plan growth, one Wall Street analyst is clear where it’s coming from: ‘private MCOs which are fragmented and subscale’. The largest MA plan, with almost 8 million members, captured roughly one out of every three people who joined Medicare Advantage this past year.

Track them and evaluate their product offerings, market messaging and selling tactics. Learn from your biggest competitors.

TMOs, EMOs and More

These third-party marketing organizations or ‘aggregators’ are disrupting the lead funnel with big investments in direct-to-consumer marketing schemes. With more than a dozen of these well-funded, commission- driven brokers, selling MA plans from multiple carriers, they’re eating into ‘lead share’ across the country. They’ve also gotten CMS’s attention after mounting complaints from consumers who reported being confused and misled. In 2020, CMS received 15, 497 complaints related to marketing, this past year there were 39,617 complaints, many tied to TMO activities. CMS’ 2023 proposed rule seeks to tighten marketing oversight and scrutiny. The biggest concern by carriers on business produced through aggregators is poor retention (i.e., rapid disenrollments, high ‘dropout’ rates).

Embrace direct response marketing tactics that work – data-driven targeting, compelling offers and creative, action-oriented messaging, and test, test, test!

Pre-AEP

Before AEP starts, ‘market warming’ with mail and DRTV continues to payoff. In fact, many say that if a plan misses pre-AEP market outreach, they’ve missed most of the available leads for the period. For some plans these early leads represent over half of all AEP volume. The big caution: it only works if your sales funnel and call center are prepared to handle these volumes and, most importantly, a ‘lead nurturing’ plan and process in place to optimize the value of these leads (e.g., responder non-converters do convert at higher rates). The other piece of the pre-AEP puzzle is brand building. Your plan’s brand is its relationship with the market, its reputation, and its promise to customers. Brand building throughout the year backs-up and bolsters every piece of lead generation marketing put into the market during AEP. Strong brands increase market share in highly competitive markets.

Be in front of your prospects during the year, particularly leading up to the start of AEP. Capitalizing on local presence and its associated value proposition to prospective members can be a powerful counter to national competitors.

The Workhorse

Direct mail is still proving to be Medicare Advantage’s direct response pillar. While recently plans have seen a year-over-year decline in response and lead rates, from a cost per lead standpoint it’s hard to beat mail: low cost, high conversion! That said, paid digital media is catching up, particularly on a cost per member basis. The big unknown is how much mail is driving people to the Web but not tracked and reported. One addition to the direct mail mix being used more frequently (as well as in other channels) are QR codes to gather leads faster (let’s be honest, who hasn’t interacted with a QR code restaurant menu over the past year?).

Direct mail isn’t dead! It remains a fundamental part of an integrated omnichannel MA marketing strategy…make it standout and optimize its lead generation ROI.

Star Ratings

About 70% of MA plans have 4 or more Stars…does it really matter to the consumer? Research shows that consumers don’t really understand CMS’ rating system. While it may not be integral to consumer decision making, a 4-Star rating is clearly competitive table- stakes in today’s MA marketplace. Putting together a competitive plan at 3.5 stars that has to go head-to-head against a 5-star plan isn’t a winning situation. And while conventional wisdom has been that these ratings don’t move the needle, a 5-Star rating does matter, particularly when it comes to bonus payments and the advantage of year- round acquisition emphasizing the 5-Star rating. If you got it, flaunt it!

CMS is changing Star rating guidance so pay attention to be sure your plan doesn’t slip and continues its journey to 5 Stars

Old School

Business Reply Card (BRC) performance is holding its own, generating a high percentage of leads when compared to digital and phone…especially pre-AEP (although in some markets slow postal processing impacted results). Again, diligent nurturing of these leads is a critical success factor. In terms of in-person vs. virtual seminars, some markets have seen pandemic-weary seniors willing to get out of their house to attend seminars again (FSIs remain primary promotion tactic). Elsewhere, after 2 years of Facetime and Zooming, prospects are more comfortable with a virtual event showing that ‘senior tech’ barriers may be weakening. But for many plans, low utilization of both in- person or virtual has meant no seminars at all. Continued investment in seminars is fading fast.

Old school or new, developing, engaging, and reinforcing your prospect relationships throughout the sales funnel makes lead nurturing a best practice for every successful MA plan.

Digitalization

Plans continue to increase digital customer acquisition budgets, but results are mixed. In many markets, search and social have performed well. Social had much stronger performance than previous years against efficient lead generation, proving the pandemic increased senior use of social media. Well-funded paid search that pulls though other channels can also be a strong lead generator. Aggregators also spent big in paid search. However, while it makes sense to follow the digital marketing trend, it’s not always as efficient, and conversions are lower compared to direct mail. Without question, digital should be part of any multichannel approach, but overall, the market isn’t there yet in terms of pushing the bulk of the acquisition marketing budget into this channel.

Balance is everything when it comes to the acquisition digital experience. It’s still more heavily weighted toward shopping vs. purchasing and budgeting needs to follow the market, not get ahead of it.

Supply Chain

Covid is disrupting and reshaping supply chains across industries, and Medicare Advantage marketing is no exception. From paper inventory and staffing shortages to print production capacity to delays of USPS first- class mail, even private freight, MA plans struggled with logistics throughout AEP. Timely in-home mail was probably most affected, and it affected everyone. It’s beyond Murphy’s Law! Supply chain issues will continue to create a volatile, unpredictable environment so plan for it and set realistic expectations to minimize late-stage anxiety and panic when the unforeseeable happens.

Plans must build supply chain unknowns into their go-to-market schedules going forward: start earlier than ever and give longer lead times for internal processes and budget approvals. Put another way: expect the unexpected!

Product Differentiators

What topped the list this past year: Part B premium givebacks and OTC allowances. And $0 premium or low dollar PPOs have emerged as the new normal, making these products a must have, since they’re available in every market. For consumers, MOOP “maximum out- of-pocket” is more important than ever, along with the overall monthly spending (which makes Part B givebacks a disruptor). But beware, one plan’s giveback was so popular they had to discontinue the offering given customer service challenges and low profitability. Benefits such as meals, transportation, dental, vision, and in- home support can also be found everywhere, creating a plan benefit ‘sea of sameness’. Figuring out how to turn these supplemental add-ons into effective marketing tools is tricky, but they can work to a Medicare plan’s advantage (no pun intended).

Not having a competitive MA product offering is a market killer – wasted lead generation dollars. Use in-depth market insights to understand how your products stand up in the competitive landscape; look back, look forward, and make informed product decisions.

Coming in the next post:  Part II - Next Up: Time To Get Real

Platform mutual aid for healthcare coverage in China

by Rong Yi, Milliman, February 10, 2022

Since 2012, China has achieved near-universal health coverage through a set of sweeping national health reforms. The basic social health insurance mostly covers inpatient services. Outpatient and prescription drug coverage are not yet standardized within China, and the levels of benefits vary significantly by geography. Along with rapid economic growth, urbanization, and an aging population, a growing demand has emerged for healthcare services and for better healthcare coverage. As a result, commercial health insurance has also been growing rapidly.

Traditional life insurers have been dominating the commercial health insurance market in China. In recent years, large IT companies or their investment arms have been making headways into the healthcare space. Leveraging digital technology and direct access to individual consumers, they are actively involved in both the “2B” (business-to-business) and “2C” (business-to-consumers) fronts. They aggregate consumer data to support health insurance underwriting and sales, or act as sales channels to insurers. On the 2C front, they provide personal health and lifestyle management as add-on services to their existing users, technical solutions for patient engagement, appointment booking for office visits, mobile payment for healthcare expenses, health insurance billing, and more. These IT giants have also started to partner up with insurers to offer health insurance products. As the “new kid on the block”, the companies bring in not only capital and technology but also unique vision and strategy on how to grow health insurance business. It is against this context and backdrop that platform mutual aid was spawned and took hold in China. Platform mutual aid programs are risk-pooling and mutual aid mechanisms built on large digital platforms. In this paper, we will discuss what they are, what they are not, and how they work.

What works in China’s market may not work in other parts of the world. In fact, as we complete this article at the end of 2021, the industry has seen permanent closures of mutual aid programs started by the most prominent platform companies, such as Meituan Mutual Aid, Waterdrop Mutual Aid, and Qingsong Mutual Aid in the course of 2021.[1] The leader of platform mutual aid in terms of membership, Xianghubao, is a product developed by Ant Financial, a subsidiary of Alibaba that has gone through dramatic changes since its inception in 2018.[2] Xianghubao grew to enroll more than 100 million members in its first year, plateaued in the second year, and has started to decline in membership since the start of 2021 due to concerns over the cancellation of Ant Financial’s initial public offering (IPO). On December 28, 2021, Ant announced that Xianghubao will officially close in a month.[3]

While rapid change is characteristic of any new form of business, especially in China, the impact of platform mutual aid programs has been felt in almost all corners of China’s burgeoning health insurance market. New market rules and regulations were rolled out to regulate the platform mutual aid programs.

We do not wish to speculate on the future direction of platform mutual aid business as a whole. As independent observers, we think that the platform mutual aid model is worth studying as a business phenomenon for its concept, design, execution, and technology. It may inspire further innovations in insurtech, which hopefully would grow more robust in the future. Platform mutual aid has also challenged China’s health insurance industry and pushed it to innovate and stay competitive in parallel for its own viability.

What is platform mutual aid?

Platform mutual aid programs were born in the era of digital economy in China. They make use of platform technology to create risk pools for participating individual members to cover defined sets of medical conditions against each other. Many programs started with making fixed reimbursement payments similar to those of critical illness insurance, and later changed to making reimbursements of medical expenses. Participants typically are users of internet-based social network platforms or e-commerce platforms, with a set “desirable” personal attributes such as good credit history, long purchase history, stable income, etc. Unlike conventional commercial health insurance, participants do not go through an explicit medical underwriting process, but instead are invited to participate or automatically opted in by the platform, based on their user profile. The platform sets up the rules as to the kind of disease conditions and medical expenses eligible for reimbursement payments, analogous to a conventional health insurance policy’s product design.

Take Xianghubao as an example. Members obtain eligibility automatically if they have been a user of Alibaba’s e-commerce platform and have a good credit standing. There is no up-front membership fee. One of the most critical success factors in mutual aid is membership. After all, mutual aid and insurance programs are both risk-pooling and risk-sharing mechanisms that become more stable and cheaper to operate as total enrollment increases. In this case, Ant Financial is able to leverage consumer data collected from its affiliated businesses to prescreen participants and then leverage its large user base for program launch, both of which have low overhead and low operating costs.

To receive a payment from the program when losses occur, Xianghubao has a multistep verification process to ensure the authenticity and accuracy of the claim. After verification, each claim will also go through a public exposure period, during which the claim will be under the community’s review and approval to further reduce fraud and abuse. For cases in which the community cannot reach a consensus to approve, a jury system with representatives from the user community would make the final decision. If a claim is denied after all of these due processes, Xianghubao still has an additional channel, called "Xianghubang" (“bang” means help in Chinese), which collects charity donations on behalf of the claimant, independently of the Xianghubao channel.

FIGURE 1: PLATFORM MUTUAL AID BUSINESS MODEL

 

Mutual risk-sharing mechanisms are by no means new. They have existed since long before formal insurance was established, and are still quite popular in today’s world, especially in developing countries, agrarian societies, and rural areas where income fluctuations are large and formal credit and insurance markets are less robust.[4]

Traditional informal mutual risk mechanisms rely on social networks—family, relatives, friends, coworkers, neighbors in the same village, etc.—to establish the risk pool. It is conceivable that personal relationships cannot go very far, because interpersonal trust and credibility become weaker as relationships become less direct.

Platform-based mutual risk programs make use of digital technology and can reach very large numbers of participants. The participants in the same mutual program are not required to know each other, but they share a common belief, which is that the platform will take care of the credentialing of the participants, make sure that claims can be paid, and take necessary measures to combat fraud, waste, and abuse. Not every platform can do all of these easily. Only organizations with strong market positions as a digital platform, long tenure, great technology, and the ability to operate in full transparency are able to attract enough participants to form a risk pool of meaningful size.

Any mutual risk-sharing arrangement will encounter issues such as asymmetric information, adverse selection, and moral hazard, and platform mutual aid programs are no exception. Fundamental actuarial and insurance business principles still apply.

Evolution of platform mutual aids in China

China's platform mutual aid programs started about 10 years ago. In the initial years, a few dozen mutual aid programs mushroomed almost overnight. Many of the early mutual aid programs were perceived by the general public to be in a gray zone between formal insurance and charity.[5] Due to the limited number of participants, many mutual aid programs closed down quickly. One of the earliest programs that is still in existence today is Kang-Ai.[6] It was inspired by the founder’s personal experience with cancer.[7] Now it has expanded to include separate risk pools for at least 50 catastrophic conditions, such as breast cancer, pediatric blood cancer, rare diseases, chronic conditions with complications, accidental deaths, sudden deaths for entrepreneurs under the age of 50, and more. It even provides risk pools for members’ elderly parents.

Since 2016, as more large internet companies entered the competitive landscape and further crowded out smaller mutual aid programs, business models started to mature. For instance, the insurtech company Waterdrop[8] rolled out its mutual aid program, Waterdrop Mutual Aid, in May 2016. Waterdrop also recommended plans from insurance companies to mutual aid members. It was reported that close to 40% of users who had participated in Waterdrop’s mutual aid also subsequently thought about buying insurance products.[9] After all, Waterdrop’s business objective was to grow its insurance business. Mutual aid was viewed as a way of customer acquisition and retention. It also educated the users on risks and protection through educational content provided to its members. Companies such as Ant Financial (of Alibaba), Suning (mostly known as the network for household electronics and appliances), 360 (a technology company), Meituan (similar to Groupon in the United States), Didi (ride hail platform), and Baidu (internet search company, similar to Google in the United States) also established their own mutual aid programs.

Membership growth in platform mutual aid was spectacular between 2016 and 2020. In 2019, platform mutual aid programs in China enrolled about 150 million members.[10] By the end of May 2020, about 330 million people were participating in platform mutual aid.[11] Xianghubao, by Ant Financial/Alibaba, the largest platform mutual aid program in China, started in December 2018, had a membership of 23 million in January 2019, and reached 100 million members in December 2019.[12]

FIGURE 2: DEVELOPMENT OF PLATFORM MUTUAL AID

 

What typically happens with innovations, especially the disruptive kind, is that market rules and regulations take time to catch up to suit the new competitive landscape and social values. Additionally, from a forward-looking standpoint, heavy-handed regulation may run the risk of stifling innovation. Mutual aid shares characteristics with both insurance and charity but is neither. In practical terms, deciding which government oversight entity or entities should have the jurisdiction, what provisions are needed in the regulations, and how to execute them all still need to be sorted out in China.

In July 2017, the Ministry of Civil Affairs issued regulation on fundraising by charities using the internet platforms.[13] It stipulates that platform mutual aids are not charity fundraising activities. In August 2020, the China Banking and Insurance Regulatory Commission published an article in an industry journal[14] and identified a number of critical issues and market risks to be addressed in platform mutual aid from a regulatory standpoint. It then followed by issuing a set of rules[15] in December 2020, forbidding unlicensed entities to carry out insurance business through the internet. There is not yet a formal set of market rules specific to platform mutual aids as far as we are aware.

During the COVID-19 pandemic, coupled with the aforementioned regulatory controls, China’s platform mutual aid programs have started to see membership declines since mid-2020. Meituan Mutual Aid shut down its program in January 2021. Waterdrop Mutual Aid and Qingsong Mutual Aid both announced plans to shut down their programs in March, after nearly five years in operation. Ant Financial’s cancelled IPO negatively impacted Xianghubao’s membership, which dropped down to 92.7 million in April 2021 from its peak at 105.8 million in November 2020.[16]

Member characteristics

While the platform mutual aid industry goes through rapid changes, who are the members, and how have they been impacted by mutual aid?

In May 2021, Ant Group Research Institute published a white paper on the platform mutual aid industry.[17] It is the first of its kind for China. Through a large questionnaire-based survey, Ant collected data on about 59,000 representative individuals and analyzed the socioeconomic characteristics of the study population sample. The report finds that members participating in platform mutual aid predominantly have middle-to-low incomes, reside in less developed regions, and because they have not purchased any commercial health insurance they are concerned about the cost associated with catastrophic diseases.[18] Additionally, almost 13% of the sample did not enroll in the national basic social health insurance program, whereas, at the national level, only around 5% of the population is not enrolled in a typical year m. Almost half of the members participated in mutual aid as a family.

In terms of member perception or user experience, more than 92% of the survey respondents (through a multiple-choice question) say that it helps to "relieve the burden of medical expenses for serious illnesses."[19] Hope that mutual aid could provide long-term healthcare costs was also indicated by 40% of the respondents. In addition, a big majority expressed interest in seeing the mutual aid programs cover more disease conditions, supply adequate financial protection, and provide prompter payouts.[20]

In fact, other public sources reported in mid-2021 that Waterdrop Mutual Aid had helped more than 21,000 families during the more than five years of operation, and Xianghubao helped more than 100,000 individual members since its inception. We do not have more updated data on program payouts, especially on how many additional individuals and families have received payment since then. On the other hand, there have been reports[21] on the increase in management fees and greater inclination to deny payment requests, which seem to have resulted from reductions in membership, lack of market oversight, and changes in the general public’s sentiment about platform mutual aid as a credible and reliable source of coverage. These factors play together and propel each other, which seems to be leading the entire industry down a rapidly deteriorating path.

Technology innovations to address old problems

Membership and risks are the two most critical factors that a platform mutual aid program needs to address. To pare it down, each factor also has multiple layers of challenges underneath. 

• A successful program needs a large member base to be financially viable—the law of large numbers in Insurance 101. Internet companies, social media platforms, e-commerce giants, and the like are naturally well positioned in reaching large numbers of members. After all, their users often interact with the digital platform constantly.
•  There needs to be a screening process for the kinds of members a platform wants to enroll in a risk mutual, analogous to insurance underwriting. Traditional underwriting process in insurance can be quite costly. In the ecosystem of a platform economy, desirable member characteristics that are correlated with lower risks can be more easily identified and filtered on. In fact, most if not all e-commerce platforms and technology companies have accumulated customer data, some of which include lifestyle and other health-related information. Such information can be used to develop risk profiles at the member level for screening.
• Once members sign up, retaining their membership is yet another layer of challenge. Platform mutual aid programs compete fiercely against each other and also with traditional commercial health insurance that covers the same or similar medical conditions but with guaranteed payouts. As a result, they are compelled to  lower management fees while maintaining the credibility that they will have sufficient funds to operate, to combat fraud, and to make payments. It is conceivable that without adequate investment and continuous cash flow to support the business operations, a program could easily fail before it reaches stability. This is apparent not only to the mutual aid programs themselves, but also to the participating members. Members who are risk-averse may prefer to participate in programs backed by a big widely known name, because large platforms are less likely to fail and they can also endure losses in the initial year by cross-subsidization. For instance, Xianghubao has not become profitable since its inception in late 2018. As a business unit its only source of revenue is an 8% management fee, and 40% of the management fee is spent on claims investigation and verification onsite.[22]
• Program transparency is critical in a mutual aid program that does not rely on members knowing each other directly. A transparent process in handling claims may increase the credibility of the program and reduces unnecessary disputes among participants, which may subsequently improve program efficiency. Blockchain technology, for what it is, may be a perfect solution to the transparency and credibility issue. For instance, Xianghubao uses blockchain to document each claims settlement and makes it available for the community of participants to review and monitor. In fact, blockchain technology has been used in China’s insurance industry in documentation, health statement authentication, creating excess claims, and authenticating linked insurance products from different lines of business.[23]
• Similar to traditional insurance, platform mutual aid programs need to control risks and mitigate losses. Losses are directly associated with the provision of healthcare, which varies by many factors such as practice location (e.g., urban vs. rural), setting (inpatient or ambulatory), provider specialty, training and preference, financial reasons that motivate providers and patients in different ways, etc. Even if a claim has been determined as valid, the mutual aid program still needs to determine, on behalf of the community and for the benefit of the community, what portion of the claimed losses is compensable and what portion is not. A guiding principle is that the program does not pay overuse or inappropriate care. Again, as a leader in digitization, Xianghubao applies digitized disease-specific guidelines and knowledge maps for treatment protocols as needed.[24]   

FIGURE 3: DIGITAL TECHNOLOGY IN PLATFORM MUTUAL AID

Factors to consider in future growth

We are independent observers and do not wish to opine on the future directions of any specific company or of the entire platform mutual aid industry. However, we think that there are a few considerations to take into account with respect to the future growth of platform mutual aid and, along the same lines, how it interacts with other players in China’s healthcare coverage ecosystem. In Figure 4, we identified market and regulatory forces in the healthcare ecosystem that could either contribute to the growth of platform mutual aid or compress its growth potential. It is worth pointing out that the most important dynamic in China’s healthcare is the policy direction of the national basic social health insurance. Because China's basic social health insurance covers the basic healthcare needs of 95% of the population, its expansion or contraction will likely have significant impact on commercial health insurance, platform mutual aid, and all other stakeholders in the healthcare ecosystem.

The closure of Xianghubao, the largest player in platform mutual aid, certainly has deep implications for platform mutual aid programs and the insurance industry, which may take some time to play out. There are a few highly valuable innovations that the insurance industry can benefit from, such as the use of blockchain technology for authenticating claims, the data-driven approach to claims adjudication, the combination of clinical guidelines and artificial intelligence (AI) to identify potential waste, and the individualized and targeted member outreach and education.

Platform mutual aids also have the ability to form risk pools at speeds unheard of in traditional insurance, because it reaches members directly through an existing platform and completely bypasses the underwriting process. Insurance companies will not give up medical underwriting unless it is required, but some have contemplated simplifying underwriting to speed up the enrollment process. To do so, they collaborate with platform companies and use them as targeted marketing and sales channels.

Platform mutual aid programs are able to form risk pools for very specific risks, such as Kang-Ai’s risk pool for sudden deaths among entrepreneurs under the age of 50. For additional background, while there is insufficient empirical data on sudden deaths among entrepreneurs under the age of 50, such deaths usually make headlines in the news and cause a lot of public attention. It is as if where there is public sentiment about a perceived risk, there would be a risk-sharing arrangement that a platform can build. While this level of flexibility and nimbleness is unparalleled in commercial insurance, it certainly has challenged the way insurance companies think about product designs. Is the under-50 entrepreneur sudden death risk different from the population average? How should the risk be appropriately priced? Does it make business sense to design such a product?

FIGURE 4: RELATIONSHIP BETWEEN COMMERCIAL INSURANCE AND BASIC SOCIAL HEALTH INSURANCE

 

As the end of 2021 draws near, the COVID-19 pandemic is still making waves throughout the world. During this difficult time, people are ever more reliant on platforms to communicate and to do business with each other. At the same time, big platform companies are also facing increased government oversight and public scrutiny. These factors will impact the future of platform mutual aid programs. 

Limitations and Caveats

In conducting the background research of platform mutual aid in the past year, we referenced numerous news articles and industry reports. We were only able to do cross-validation of the statistics cited by these sources but are unable to independently verify the statistics ourselves.

The authors are employees at Milliman and do not have any interest in any of the businesses mentioned in this article.

The observations are entirely those of the authors and do not represent those of Milliman.

The authors thank Wendy Liu for her diligent research, Guanjun Jiang, and other Milliman colleagues for peer review and input.

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[1] Xuemeng, H. (April 21, 2021). Regulators stress that "licensed driving" online mutual aid platforms face choices. China Financial News Network. Retrieved January 20, 2022, from https://www.financialnews.com.cn/bx/bxsd/202104/t20210421_217028.html.

[2] Wall Street Journal (May 6, 2021). Ant Looks to Revamp a Controversial Business Without Sparking an Outcry.

[3] Reuters (December 28, 2021). Update 1 – China's largest online mutual aid platform curtain call, Ant Group's "Mutual Treasure" will be closed in one month. Retrieved January 20, 2022, from https://www.reuters.com/article/idCNL4S2TD1BJ.

[4] Informal mutual risk sharing has been well studied by economists since the late 1980s. One of the most prominent economists, Angus Deaton, awardee of the 2015 Sveriges Riksbank Nobel Prize in Economic Sciences , practically initiated a whole field within economics on how individuals and households use informal mutual risk-sharing arrangements to cope with income fluctuations in the absence of formal mechanisms.

[5] Quite a few media outlets had commented on the need to differentiate between mutual aid and charity, including the most widely read ones, such as http://www.xinhuanet.com/comments/2021-05/06/c_1127411101.htm, and http://www.xinhuanet.com/comments/2021-05/06/c_1127411101.htm.

[6] See the Kang-Ai website at http://www.kags.cn/.

[7] The story of how Kang-Ai was founded can be found on its website at https://www.kags.cn/#:~:text=%E5%9B%A0%E6%AF%8D%E4%BA%B2%E7%99%8C%E7%97%87%E5%8E%BB%E4%B8%96%E3%80%81%E7%88%B6%E4%BA%B2,%E6%97%A5%E8%87%BB%E5%AE%8C%E5%96%84%E7%A8%B3%E5%81%A5%E5%8F%91%E5%B1%95%E4%B8%AD%E3%80%82.

[8] See the Waterdrop website at https://www.waterdrop-inc.com/.

[9] Wei, J. (March 30, 2021). Waterdrop mutual aid is closed! Tens of millions of members and 4 billion financing, why did it come to the end? Sohu.com. Retrieved January 20, 2022, from https://www.sohu.com/a/458091396_157944.

[10] Ibid.

[11] Ibid.

[12] Ibid.

[13] China Ministry of Civil Affairs (July 30, 2017). Announcement of the Ministry of Civil Affairs on Issuing Two Industry Standards Including "Basic Technical Specifications for Internet Public Fundraising Information Platforms for Charitable Organizations." Retrieved January 20, 2022, from http://www.mca.gov.cn/article/xw/tzgg/201707/20170715005320.shtml.

[14] China Insurance Security Fund (August 31, 2020). Voice of Supervision: Analysis of Illegal Commercial Insurance Activities and Countermeasures and Suggestions (No. 4, 2020). Retrieved January 20, 2022, from http://www.cisf.cn/fxgc/zdtj/2730.jsp.

[15] China Government (December 7, 2020). Order of China Banking and Insurance Regulatory Commission (2020 No. 13). Retrieved January 20, 2022, from http://www.gov.cn/zhengce/zhengceku/2020-12/14/content_5569402.htm.

[16] Zhai, K. et al. (May 6, 2021). Ant Looks to Revamp a Controversial Business Without Sparking an Outcry. Wall Street Journal. Retrieved January 20, 2022, from https://www.wsj.com/articles/ant-looks-to-revamp-a-controversial-business-without-sparking-an-outcry-11620293404?page=1.

[17] See https://antcloud-cnhz02-athomeweb-01.oss-cn-hzfinance.aliyuncs.com/attachment/2020-06-13/3f900e1a-d421-49ba-a635-bb9792a0179f.pdf. The report commented that this could be a result of selection bias, meaning that individuals who did not participate in China's national basic social health insurance are more inclined to join a mutual aid arrangement to get some health coverage. On the other hand, the report also recognized that there might be a problem with underreporting in the data collection process.

[18] Ibid.

[19] Ibid.

[20] Ibid.

[21] For instance, see https://www.sohu.com/a/458130739_564023 and http://www.21jingji.com/2021/5-8/0OMDEzODBfMTYyNDU0OQ.html.

[22] Xiaoyi, H. (May 8, 2021). When the online mutual aid exits the market in 3 months, where is the mutual treasure road that has lost more than 8 million users? 21st Century News Group. Retrieved January 20, 2022, from http://www.21jingji.com/2021/5-8/0OMDEzODBfMTYyNDU0OQ.html.

[23] Zero One Think Tank (July 2020). Insurance industry, another high ground for blockchain financial applications. Retrieved January 20, 2022, from https://www.01caijing.com/article/266378.htm.

[24] Wei, J. (March 30, 2021), Waterdrop mutual aid is closed! op cit.

COVID in 2022: Key Components of Moving to an Endemic State

By Dr. Seleem R. Choudhury, February 3, 2022

During this current winter wave, many countries outside the U.S. continue to use blunt COVID mitigation measures that they relied on early in the pandemic. These measures, such as transitioning kids to at-home learning and closing businesses, resulted in significant social and economic costs. Yet more people died globally in 2021 than in 2020 as the virus slashed its way through older and unvaccinated individuals, raising the death toll at an alarming rate.

Nearly 800,000 Americans have died so far during the pandemic, with more than half of those deaths occurring during 2021 (New York Times, 2022). Comparatively, the Spanish influenza of 1918 infected an estimated one-third of the world’s population, resulting in at least 50 million deaths worldwide (Choudhury, 2021). The Institute for Health Metrics and Evaluation (IHME) provides COVID-19 projections bi-weekly. Based upon their current projection, by April 1, 2022, the U.S. will reach 970,243 reported COVID-19 deaths (Institute for Health Metrics and Evaluation, 2022).

There can be no doubt that the coronavirus pandemic is ongoing, serious, and unpredictable. But based on current data and past patterns, we can forecast what Spring 2022 might bring and how to best respond.

2022: Beyond winter, into spring 

The number of deaths worldwide from COVID-19 is horrific, especially when you consider that around seven in 10 U.S. adults (72%) report that they personally know someone who has been hospitalized or died from COVID-19 (Tyson, Funk, Kenney, & Johnson, 2021). Though devastating, the “silver lining” is that in terms of pandemics, what is happening now is not unusual. As Charumilind, et al., explains: “Epidemics end in one of two ways—either we close off all chains of transmission and drive cases to zero, as with all Ebola epidemics to date, or the disease becomes an ongoing part of the infectious-disease landscape, or endemic, as tuberculosis is today” (2021).

Societal impact

Now, on what is hopefully the verge of moving from a pandemic to an endemic, is the time for governments and countries to create a vision for what the new normal will look like and build consensus around it.

In the last two years, the COVID-19 pandemic has had a profound impact on lives and livelihoods, but response and action beyond vaccination and testing is different from nation to nation. Some countries close their borders, while some remain open. Some introduce a fourth vaccination shot, and others a “circuit breaker.” Some have closed shops and businesses, and some have not introduced anything different at all.

If you examine the past data of the various COVID-19 management tactics, a common thread among strategies that have had the most success appears to be the presence of a philosophy that the COVID response is “a shared responsibility” and “everyone’s business.” While pandemic management differs widely from country to country, greater success in lessening its impacts can be achieved with a unified response (Organisation for Economic Co-operation and Development, 2020; World Health Organization, 2021).

Masking

Masks are an important intervention for mitigating the transmission of COVID, and are an essential piece of the puzzle for moving from a pandemic to endemic status (Brooks, Butler, & Redfield, 2020; Van Dyke, M., Rogers, T., Pevzner, E., Satterwhite, C., Shah, H., et al., 2020). A 2020 study of counties in the state of Kansas concluded that there is a “significant amount of clinical evidence that countywide mask mandates appear to have contributed to the mitigation of COVID-19 transmission in mandated counties” (Van Dyke, M., Rogers, T., Pevzner, E., Satterwhite, C., Shah, H., et al., 2020). Other studies have found that face masks “decrease the daily growth rate of reported COVID-19 cases by more than 40%” (Peeples, 2021).

However, masks remain a symbol of a divided society (Powdthavee, Riyanto, Wong, Yeo, & Chan, 2021). People in the same community but with “different moral concerns react differently to the recommended guidelines” (Chan, 2021). With such differing reactions to the same set of mask-related data, an important part of the work of governments and public health agencies is to implement rational mandates on appropriate face mask utilization based upon a defined “trigger system” that reacts to outbreaks on a community-by-community basis (Feng, Shen, Xia, Song, Fan, & Cowling, 2020).

Vaccination

With unprecedented global resources focused on developing a COVID-19 vaccine, a safe, effective vaccine was created in record time. A year on from the initial release of the vaccine, the scientific and medical communities are looking toward “more potent immunity, easier transport, and mutation-proofing” (Cox, 2021). A potential game-changer would be the development of a pill or a nasal spray which would make administration much easier and cheaper, especially in places where distribution is challenging, or for people with an aversion to needles (Steenhuysen, 2021).

Testing

In past public health crises, such as HIV outbreaks, widespread tobacco usage, or childhood obesity, public health agencies engaged in campaigns to increase access to testing. Historically, testing has improved health outcomes in the spread of sexually transmitted diseases, teenage pregnancies, tobacco cessation programs, health disparities in cancer, and childhood obesity, to name just a few. Building on lessons learned from access to testing—or the lack thereof—during the COVID-19 pandemic, there are significant opportunities to expand access to testing, whether in the hospital, clinic work, school, or at home.

Access to testing is a must when trying to isolate a fresh wave or outbreak of COVID (Pletcher, Olgin, Peyser, et al., 2021). A lack of access to testing results in people spreading the virus without knowing they are positive and also further overburdens a healthcare system that is already overwhelmed (Raphael, 2021; Grimm, 2021; Centers for Disease Control and Prevention, 2021).

In the U.S., the government subsidized the more-expensive PCR lab tests for uninsured people and has required insurers to cover them with no co-pay since the start of the pandemic. However, it didn’t put a similar system in place for at-home rapid tests (Schuetze, & Eddy, 2021). In contrast, many countries have already made the takeaway tests free. For example, parents in many European countries were provided with home kits to test their children prior to going to school (Bonislawski, 2021; King, Schmidt, & Perehinets, 2021). Additionally, British citizens can order packs of rapid tests from a government website to be sent to their homes at no charge (Gov.UK, 2022).

In the U.S., it is virtually impossible to purchase at-home testing kits in a pharmacy or online, even after the federal government promised to provide home kits to households (DePillis, & Umansky, 2021). If one is lucky enough to locate a kit, many shops and big chain stores significantly raised their prices for rapid test kits, making at-home testing a financial impossibility for many citizens.

Data

Data has become “indispensable as clinicians and policymakers suit up for the fight against the pandemic” (Amazon Web Services, 2021). It will be an essential tool for forecasting the impacts of the Omicron variant in the coming months, as well as helping to determine management strategies for a future endemic (Baillie, Berger, & Brockmeier, 2020; American Medical Association, 2020; Open Data Watch, 2021). The development of “a robust system to gather and analyze data” and then “use the data to act” is necessary (Nzyoka, & Dwivedi, 2020). Data can help providers isolate people and give appropriate treatment. It can also help government and public health agencies identify vulnerable or elderly populations and send customized, targeted messaging to these groups more rapidly (Nzyoka, & Dwivedi, 2020).

Conclusion

Experts say that COVID will likely lose its pandemic status sometime in 2022 and shift to an endemic (Stieg, 2021). We will once again settle into a “new normal.” Bill Gates, president of the Gates Foundation, which has been overwhelmingly successful in their mission of creating a world free of malaria through partnership, collaboration and unity, recently commented on his blog that he hoped that soon the “only time you will really have to think about the virus is when you get your joint COVID and flu vaccine every fall” (Gates, 2021).

COVID-19 has had a significant impact in accelerating transformation of practices within healthcare and private industry, from pharmaceuticals to digital capabilities to private and healthcare businesses. This transition from a pandemic to endemic requires continued agility and a robust public health program that uses data to forecast what the coming months might hold, and to address when to wear a mask, expand access to timely testing, vaccination boosters, and public health education that promotes unity, avoids politics, and fosters individual and community compliance.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com

Resources

Amazon Web Services (2021). The importance of data in the fight against Covid-19. GovInsider.

American Medical Association (2020). The role of data collection in the COVID-19 pandemic. AMA.

Baillie, K., Berger, M., & Brockmeier, E. (2020). The role of data in a world reshaped by COVID-19. Penn Today.

Bonislawski, A. (2021). Experts Weigh In Europe's Embrace of Rapid Antigen Tests for COVID-19 While U.S. Lagged. 360Dx.

Brooks, J., Butler, J., & Redfield, R. (2020). Universal Masking to Prevent SARS-CoV-2 Transmission—The Time Is Now. JAMA. 2020;324(7):635-637.

Centers for Disease Control and Prevention (2022). National Health Initiatives, Strategies & Action Plans. CDC.

Centers for Disease Control and Prevention (2021). Reduced Access to Care. CDC

Chan, E. (2021). Moral foundations underlying behavioral compliance during the COVID-19 pandemic. Personality and Individual Differences. 171: 110463.

Charumilind, S., Craven, M., Lamb, J., Singhal, S., & Wilson, M. (2021). Pandemic to endemic: How the world can learn to live with COVID-19. McKinsey.

Choudhury, S. (2021). Monitoring the safety and effectiveness of COVID-19 vaccines. Blog.

Cox, D. (2021). What will tomorrow's Covid-19 vaccines be like? BBC.

DePillis, L., & Umansky, E. (2021). Here’s Why Rapid COVID Tests Are So Expensive and Hard to Find. ProPublica.

Feng, S., Shen, C., Xia, N., Song, W., Fan, M., & Cowling, B. (2020). Rational use of face masks in the COVID-19 pandemic. The Lancet.

Gates, B. (2021). Reasons for optimism after a difficult year. GatesNotes.

Gov.UK (2022). Order coronavirus (COVID-19) rapid lateral flow tests. Gov.UK.

Grimm, C. (2020). Hospital Experiences Responding to the COVID19 Pandemic: Results of a National Pulse Survey March 23-27, 2020. U.S. Department of Health and Human Services, Office of Inspector General.

Institute for Health Metrics and Evaluation (2022). COVID-19 Projections, United States. IHME.

King, K., Schmidt, T., & Perehinets, I. (2021). Cross Country Analysis: What precautionary strategies have countries taken in school settings in light of the recent rollout of vaccination programs? COVID-19 Health System Response Monitor.

New York Times (2022). Coronavirus in the U.S.: Latest Map and Case Count. New York Times.

Nzyoka, R., & Dwivedi, V. (2020). Real-time Data Could Save More People from Covid-19. New Security Beat.

Open Data Watch (2021). Data in the time of COVID-19. Open Data Watch.

Organisation for Economic Co-operation and Development (2020). The territorial impact of COVID-19: Managing the crisis across levels of government. OECD.

Peeples, L. (2021). What the science says about lifting mask mandates. Nature.

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Powdthavee, N., Riyanto, Y., Wong, E., Yeo, J., & Chan, Q. (2021). When face masks signal social identity: Explaining the deep face-mask divide during the COVID-19 pandemic. PLoS ONE 16(6): e0253195.

Raphael, T. (2021). Why Is It So Hard to Get a Rapid Covid Test in the U.S.? Washington Post.

Schuetze, C., & Eddy, M. (2021). Germany Makes Rapid Virus Tests a Key to Everyday Freedoms. New York Times.

Steenhuysen, J. (2021). Analysis: COVID-19 pills are coming, but no substitute for vaccines, disease experts say. Reuters.

Stieg, C. (2021). The Covid pandemic could end next year, experts say — here’s what that looks like, and how the U.S. could get there. CNBC.

Tyson, A., Funk, C., Kenney, B., & Johnson, C. (2021). Majority in U.S. Says Public Health Benefits of COVID-19 Restrictions Worth the Costs, Even as Large Shares Also See Downsides. Pew Research Center.

Van Dyke, M., Rogers, T., Pevzner, E., Satterwhite, C., Shah, H., Beckman, W., Ahmed, F., Hunt, D., & Rule, J. (2020). Trends in County-Level COVID-19 Incidence in Counties With and Without a Mask Mandate — Kansas, June 1–August 23, 2020. Morbidity and Mortality Weekly Report. 2020 Nov 27; 69(47): 1777–1781.

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The Tests Were a Test

by Kim Bellard, January 28, 2022

Raise your hand if you’ve gone out shopping for home COVID tests, only to find empty shelves and signs apologizing for the lack of availability.  Raise your hand if you’ve been able to obtain one, but were surprised at its cost.  Raise your hand if you took one and weren’t quite sure you did it right, or wondered who, if anyone, would be getting the results.

Vox says that the COVID home test reimbursement process “is a microcosm of US health care,” and I think they’ve understated the situation.  Testing has been a microcosm for the US health care system generally.  It was a test, and our healthcare system failed.

Throughout the pandemic, we’ve never had enough tests or done enough testing. We didn’t take advantage of macro-tracking approaches like wastewater monitoring.We developed “rapid” tests but questioned their accuracy.  The “gold standard” PCR tests took/takes too long to return results.  As we encountered the highly transmissible variant Omicron, we didn’t scale up the production of tests – or the labs to process them -- enough to keep up with the demand, much less with the number of acquired cases.  

In our free-for-all pricing system, it’s anyone’s guess what a test might cost.  Most PCR tests have been required to be covered “first dollar” by insurance plans, so consumers haven’t been immediately faced with how much those tests cost, but costs picked by insurance end up in premiums eventually.  Home tests have not been, and costs might vary ten-fold or more depending on the manufacturer and/or seller. 

The Biden Administration has belatedly attempted to address these problems, but in a ham-handed way that is also typical for our healthcare system.  Earlier this month, it set up a system to for each household to order 4 free home tests.

The Biden Administration also required private insurers – but not Medicare -- to pay for 8 home tests per member per month, which seems to have come as a surprise to the insurers.  In many, perhaps most, cases, individuals would have to submit claims to their insurer to get reimbursed for these tests.  Insurers only have to pay up to $12 per test; consumers must pay anything above that.  Surprise!

When I read about that process, as a former health insurance executive, I immediately thought: that is not going to work.

What documentation needs to be submitted (receipts, product codes, pictures of the test, etc.), and how, are still unclear, and will vary between health insurers.  

As bad as all that is, we now have a scenario where there are potentially hundreds of millions of tests being taken, but no system for tracking how many are used, by who, or how many positive results there are.  We thought we were doing a bad job counting how many people have received how many doses of the vaccine, but at least there was some reporting system in place.  With these tests, we’re pretty much going to be in the dark.  We’ll never know how many positive cases we’ve had.

Initially, we had no testing strategy.  Then our testing strategy was just “get tested,” with no supporting tactics to make that feasible.  Then, almost 2 years in, we get grand announcements about directly providing free tests, but not enough for everyone, plus mandates on insurers for more free tests that don’t do anything to make the tests more available, affordable, or easy to get reimbursed for.

Yeah, all that sounds like a microcosm of our healthcare system.  As Vox put it, “It’s a needlessly complicated process that provides little benefit but creates plenty of problems.”

Shame on us.  It’s not just the healthcare system that failed the test.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)  

The Big Picture: Healthcare 2022 - Trends, Predictions Challenges & Opportunities

by Lindsay Resnick, January 20, 2022 

Health brands are jumping on the transformation bandwagon. We need to change. We need to modernize. The health sector needs to reimagine itself. And needs to do it around the customer.

This collection of curated factoids can help health brands not only contend with market realities, but anticipate change. Think of it as context for the futurity of today’s decisions. An opportunity to step back to assess ‘big picture’ healthcare trends to inform core enterprise planning from vision to strategy to in-market tactics.

 

The first six factoids are provided below. To download the full set of 24 factoids from Wunderman Thompson Health, go here: https://www.wundermanthompson.com/expertise/health